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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602151
Report Date: 04/26/2023
Date Signed: 04/28/2023 12:56:09 PM

Document Has Been Signed on 04/28/2023 12:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:OAKHORNE MANORFACILITY NUMBER:
198602151
ADMINISTRATOR:AGATEP, EVANGELINEFACILITY TYPE:
740
ADDRESS:1584 OAKHORNE DRIVETELEPHONE:
(310) 517-9602
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 4DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Caregiver Araceli Villanueva TIME COMPLETED:
03:00 PM
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On 04/26/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual visit and met with the caregiver Araceli Villanueva while the purpose of today’s visit was explained. The facility is licensed to serve five (5) non-ambulatory of which 1 may be bedridden in bedroom #4 adults ages 60 and over and have a hospice waiver for 2

The facility is a one-story home located in a residential neighborhood. The property consists of the following: A staff work space, four (4) resident bedrooms, two (2) bathrooms one(1) of which is private, linen closet, dining area, kitchen, living room, outdoor shaded area and an attached garage that houses a washer and dyer, second fire extinguisher and an empty refrigerator.

LPA and caregiver toured the inside and outside of the facility, all client rooms were checked. Mattresses and box springs were in good condition, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilet and water faucets worked properly, water temperature in private restroom one (1) measured at 114.3, restroom two(2) measured at 117.4 shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to resident.

Perishable and Non-perishable food supply was checked and adequately stocked at time of visit. Kitchen water temperature measured at 118.8 F. , carbon monoxide detector was observed and operational. Last fire drill conducted on 04/03/23. Smoke detectors were working properly, fire extinguisher is fully charged and mounted on kitchen wall, toxins and knifes were locked and inaccessible to resident. First aid kit was checked and fully stocked. A landline was observed located in the staff work area. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2023 12:56 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 04/26/2023 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKHORNE MANOR
FACILITY NUMBER: 198602151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
87705 care for persons with dementia

The licenseee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on, the licensee did not comply with the section cited above as auditory door features were not operational during the time of visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
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Licensee to purchase batteries and ensure auditory door features are operable, Licensee to send proof to LPA by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2023 12:56 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 04/26/2023 at 02:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKHORNE MANOR
FACILITY NUMBER: 198602151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(B)
87307 personal accomodations and services. Bedroom furniture, while shall include, for each resident, a chair, nightstand, a lamp, or lights sufficient for reading, and a chest of drawers

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observationthe licensee did not comply with the section cited above in two of four rooms were missing a chair and lamp which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee whill ensure each room has a chair and lamp for resdients needs. Licensee to provide proof to LPA that furniture has been placed in bedrooms by POC due date.
Type B
Section Cited
CCR
87412(c)

87412(c) personnel records
Licensee shall maintain in the personnel records verification or required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review the licensee did not comply with the section cited above as staff files do not contain documentation on staff training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Licensee will submit proof of documentation that staff has been trained by POC due date,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OAKHORNE MANOR
FACILITY NUMBER: 198602151
VISIT DATE: 04/26/2023
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During today’s visit LPA did observe deficiencies; 87705(j), 87307(a)(3)(B), 87412(c). 809-D pages are attached.

Exit interview conducted with Caregiver Araceli Villanueva, appeals rights explained and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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