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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602190
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:07:50 PM


Document Has Been Signed on 09/05/2023 03:07 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:CASA DEL SOL RESIDENCEFACILITY NUMBER:
198602190
ADMINISTRATOR:JACOBS, DOV EFACILITY TYPE:
740
ADDRESS:11606 11602 W WASHINGTON BLVDTELEPHONE:
(323) 678-4426
CITY:CULVER CITYSTATE: CAZIP CODE:
90066
CAPACITY:12CENSUS: 2DATE:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Valorie HansonTIME COMPLETED:
03:10 PM
NARRATIVE
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On 09/05/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced visit to Casa Del Sol Residence. The purpose of today’s visit was to conduct the annual inspection. LPA met with Head Nurse, Valorie Henson. Facility is licensed for 12 non-ambulatory residents. The facility currently has 2 ambulatory resident. LPA Richard and Henson toured the physical plant and reviewed staff and resident records.

The facility has 3 bedrooms and 3 bathrooms. The facility conducted a fire drill on 05/23/2023.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate residents comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. The hot water temperature tested 138.5F degrees.

Food and meals are prepared in the main kitchen located in the skilled nursing facility and is brought to the residents on carts. Staff provided LPA with a waiver. The facility doesn't have a kitchen. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly. The fire extinguisher was fully charged. Carbon monoxide detector was not operational. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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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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: CASA DEL SOL RESIDENCE
FACILITY NUMBER: 198602190
VISIT DATE: 09/05/2023
NARRATIVE
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During the visit, LPA observed a screening station with sanitizer in the facility entrance and additional sanitation supplies in nursing office inaccessible to the residents. LPA temperature was not checked during the visit. LPA observed staff wearing mask. Each resident has their own individual room for isolation and required postings are throughout the facility.

According to the California Code Of Regulations (Title 22, Division 6, Chapter 8), There were 2 deficiencies observed at the time of visit. Therefore citations were issued at this time.

Exit interview held a copy of the report and Appeal Rights were provided to Head Nurse Valorie Hanson.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/05/2023 03:07 PM - It Cannot Be Edited

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: CASA DEL SOL RESIDENCE
FACILITY NUMBER: 198602190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as Follows; (2) Faucets used by residents for personal care such as Shaving and grooming shall deliver hot water. Hot water temperature controls shall maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above the hot water temperature tested 138. 3F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2023
Plan of Correction
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The head Nurse valorie Hanson adjusted the hot water temperature between 110.7F. The manager will create a plan to ensure future compliance. Head Nurse will submit the plan of correction to LPA via email. Antonine.Rchard@dss.ca.gov
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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/05/2023 03:07 PM - It Cannot Be Edited

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: CASA DEL SOL RESIDENCE
FACILITY NUMBER: 198602190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above 2 out of 4 staff Britney Cruz, and Isis Melara are missing their TB tests, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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The Head Nurse will create a plan to ensure future employees have TB test done before they can work with residents.
The Head Nurse Valorie Hanson will submit the paln of correction on 09/15/2023 to LPA via email Antonine.Richard@dss.ca.gov (323) 516-4092.
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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4