198602229-11-12-2023-11-AS-DESA-CXHRGJ-20231112120050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602229
Report Date: 11/12/2023
Date Signed: 11/12/2023 12:00:57 PM

Document Has Been Signed on 11/12/2023 12:00 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:	ARLINGTON POST GUEST HOME		FACILITY NUMBER:	198602229
ADMINISTRATOR:	LACANILAO, LAUREANA		FACILITY TYPE:	740
ADDRESS:	1433 POST AVE		TELEPHONE:	(310) 328-6086
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 5	DATE:	11/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator Laureana Lacanilao		TIME COMPLETED:	12:35 PM

NARRATIVE

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On 11/12/2023 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA met with Administrator Laureana Lacanilao and explained the purpose of today’s visit. The Residential Care Facilities for the Elderly (RCFE) is licensed for six (6) non-ambulatory residents which six (6) may be bedridden and a hospice waiver for two (2) residents; prefers to serve elderly age 60 and above. The facility is a single-story structure located in a residential neighborhood. The facility consists of a foyer, kitchen, dining area, living room, fireplace, office area, laundry room, five (5) resident bedrooms, one staff bedroom, three and a half (3 1/2) bathrooms (located in resident bedrooms), one shared bathroom, two-car (2) garage and a covered front patio. The facility does not handle residents cash resources. Facility annual fees are current during today’s visit. LPA toured and inside and outside grounds of the facility with Administrator Laureana Lacanilao. There were no bodies of water or obstructions on the premises.

LPA confirmed that Residents #1, #2, #4, and #5 are all on hospice as of 11/12/2023. All rooms were inspected. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detectors were in compliance and operational. A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate. Medications are stored, locked and inaccessible to residents.
Resident files along with medications are current. Staff files is current. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2023

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: ARLINGTON POST GUEST HOME	FACILITY NUMBER: 198602229
	VISIT DATE: 11/12/2023

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The water temperature measured 113.0 degrees F between rooms #2, room #1 and staff room. The water temperature measured 116.9 degrees F in room #4. There are two water heaters. Currently, water heater #1 controls kitchen, center bathroom, and room #1. LPA confirmed that heater #2 controls rooms #4, #5, and #6. A comfortable temperature of 75 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 10/18/23. A working telephone remains 1-310-328-6086 available. During the visit, LPA observed the facility's infection control practices.

The facility has an approved Mitigation Plan Report on file with CCLD. There were deficiencies issued in today’s visit 11/12/2023. Based on R#1, R#2, R#4 and R#5 record reviewed licensee failed to obtain a facility hospice care waiver from the Department before admitting new residents R#1 and R#2 into the facility which poses a potential health and personal rights risk to residents in care.

Advisory Notes - Technical Assistance were issued, please see LIC9102-AN.

87468(c)(2)(A)

The following deficiency were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22.

Failure to correct the deficiency may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Administrator Laureana Lacanilao.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/12/2023 12:00 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: ARLINGTON POST GUEST HOME	FACILITY NUMBER: 198602229
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)

(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. Based on R#1, R#2, R#4 and R#5 record reviewed licensee failed to obtain a facility hospice care waiver from the Department before admitting new residents R#1 and R#2 into the facility which poses a potential health and personal rights risk to residents in care.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Administrator will review Title 22 Regulations 87632(a) and submit a statement of regulations 87632 reviewed to LPA by POC date David.espana@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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2023

LIC809 (FAS) - (06/04)

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