198602226-9-22-2023-11-AS-LMOA-CVWL8B-20230922083141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602226
Report Date: 09/21/2023
Date Signed: 09/22/2023 08:31:47 AM

Document Has Been Signed on 09/22/2023 08:31 AM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	PVE MANOR		FACILITY NUMBER:	198602226
ADMINISTRATOR:	MENESES, MARK		FACILITY TYPE:	740
ADDRESS:	3916 PALOS VERDES DRIVE NORTH		TELEPHONE:	(310) 375-8996
CITY:	PALOS VERDES ESTATES	STATE: CA	ZIP CODE:	90274
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	IRENE FORMENTERA		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the annual inspection. LPA met with Irene Formentera, Area Manager and the purpose of the visit was discussed.

Facility is licensed to serve six (6) non-ambulatory residents of which one (1) may be bedridden and an approved hospice waiver for three (3) residents. The facility does not handle any of the residents’ money. This home is a single-story home consisting of: (6) resident bedrooms, (3) Full bathrooms, 1 staff bedroom, living room, kitchen, dining room, laundry room (located in the attached garage), garage and an outdoor shaded patio area.

At 10:20 am, kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents.

At 10:30 am, 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.

At 10:40 am, LPA observed the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident 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. At 11:00 am, LPA checked the water temperature in all three bathrooms, and each measured at 109 degrees F, 115.9 degrees F. and 116.4 degrees F. Fire drill was conducted on 8/17/2023.

REPORT CONTINUED IN LIC 809C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PVE MANOR	FACILITY NUMBER: 198602226
	VISIT DATE: 09/21/2023

NARRATIVE

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At 11:15 am, LPA observed the smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available.

At 11:30 am, LPA conducted records review, staff files are current however, some resident files are not current. Medication administration records (MARs) were reviewed and found to be in compliance.

LPA Montoya provided a technical advice regarding this matter:

Resident 1 uses oxygen in the facility. Staff 1 states the local fire department has not been informed in writing. LPA advised Staff 1 to report to the local fire jurisdiction that oxygen is in use at the facility.

Deficiency cited under California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency:

On 9/21/2023 at 11:30 am, based on LPA's records review, three residents (R1, R2 & R6) out of six residents do not have current appraisals.

An exit interview was conducted and a copy of Report and Appeal Rights provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/22/2023 08:31 AM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PVE MANOR	FACILITY NUMBER: 198602226
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and records review, the licensee did not comply with the section cited above. Three residents (R1, R2 & R6) out of six residents do not have current appraisals. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	The administrator shall ensure R1, R2 & R6's are conducted timely and shall arrange a meeting with the resident, the resident's representative, home health/hospice representative if applicable. Administrator shall submit copies of the current appraisals for R1, R2 & R6 to CCLD via email to lourdes.montoya@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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