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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602202
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:20:29 PM


Document Has Been Signed on 12/28/2023 01:20 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:MERIDIAN HOME CAREFACILITY NUMBER:
198602202
ADMINISTRATOR:SAN AGUSTIN, JENNIFER GFACILITY TYPE:
740
ADDRESS:20526 WOOD AVENUETELEPHONE:
(310) 533-7898
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 0DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Jemimah Mejia/AdministratorTIME COMPLETED:
01:20 PM
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On 12/28/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Jemimah Mejia/Administrator. The facility is licensed to serve (6) age range 60 and over. (4) non-ambulatory, of which (2) may be bedridden. Bedroom #3 and #4 approved for bedridden. Approved hospice waiver for (4) residents.

On 9/14/2023 at 1:26 PM, LPA Lourdes Montoya received a call from Meridian Home Care/Jemimah regarding temporary relocation of residents due to a water leak. Jemimah stated half of the facility floors was affected by the water leak and it needs to be repaired. LPA Montoya advised Jemimah that LPA Alfonso Iniguez now handles the Meridian Home Care. LPA Montoya provided Jemimah with LPA Iniguez's contact number and advised her to reach out to Iniguez's supervisor also, if needed.

On 9/25/23 RO received an email from licensee requesting an approval for eviction for all residents. On 9/26/23 LPA visited the facility an inspected the alleged water damage, LPA and administrator tour the entire facility. LPA took pictures where the water damage occurred. Licensee gave to LPA the scope of work from restoration company. Licensee stated to LPA that his plan is to relocate not evict the residents. Licensee wants to fix the water damage at the facility and once the restoration is done, he will bring back his residents. Licensee will send a new email to RO stating his plan of relocation only.

Continue on LIC 809C.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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: MERIDIAN HOME CARE
FACILITY NUMBER: 198602202
VISIT DATE: 12/28/2023
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On 12/28/2023 LPA Alfonso Iniguez visited the facility for an annual inspection. LPA and Administrator toured the entire facility, LPA observed the facility empty with no residents residing now. All residents were transferred to different facilities. LPA took pictures of the damage and the repairs done at the facility. Last resident that transferred out was on 10/20/23.

Administrator sent to LPA a copy of the relocation list; LPA will follow up with the relocation of the residents.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Administrator/ Jemimah Mejia.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2