<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602377
Report Date: 07/29/2022
Date Signed: 08/05/2022 02:29:58 PM


Document Has Been Signed on 08/05/2022 02:29 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:FAMILY CONNECT MEMORY CARE INCFACILITY NUMBER:
198602377
ADMINISTRATOR:SPIGLANIN, LAUREN MAHAKIANFACILITY TYPE:
740
ADDRESS:1747 GREENWOOD AVENUETELEPHONE:
(310) 383-1877
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 5DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mary Lou Giebel/Rosselyn FagaraganTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/29/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Montoya called and spoke with Licensee/Administrator Lauren Spiglanin and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection.

LPA met with Director of Care Mary Lou Giebel and Facility Nurse Rosselyn Fagaragan and explained the purpose of today’s visit. The facility is licensed to operate for six (6) residents ages 60 and over of which one (1) may be non-ambulatory. The facility is approved for three (3) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, two (2) bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA Montoya toured the inside and outside grounds of the facility with Director of Care Giebel and Facility Nurse Fagaragan. There were no bodies of water or obstructions on the premises. All rooms were inspected. 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. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 108.2 degrees F. A comfortable temperature 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
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY CONNECT MEMORY CARE INC
FACILITY NUMBER: 198602377
VISIT DATE: 07/29/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

LPA observed surveillance cameras throughout the common areas of the property. Director of Care Giebel stated the facility has no intention of using the cameras.

Advisory notes were issued and technical assistance was provided.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. A civil penalty of $500 was assessed.

Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Director of Care, Mary Lou Giebel.


SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/05/2022 02:29 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: FAMILY CONNECT MEMORY CARE INC
FACILITY NUMBER: 198602377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshall. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshall. (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record reviews, the licensee did not comply with the section cited above. The facility is approved for one nonambulatory but currently operating with five (5) non-ambulatory residents (R#1-#5) and one resident (R#6) who recently passed away on 7/25/2022 was also nonambulatory. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2022
Plan of Correction
1
2
3
4
The administrator shall obtain fire clearance to retain nonambulatory residents. The administrator shall contact the fire department immediately for inspection and shall submit a completed LIC 200 with a copy of the facility sketch. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 8/2/2022.
Type A
Section Cited
CCR
87405(d)(2)
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above. The administrator failed to ensure the facility has fire clearance for all nonambulatory residents. The facility is approved for one non-ambulatory resident. Based on LPA's interview with the Director of Care and record review of the Physician Reports, all five residents present during an annual visit on 7/29/22 are nonambulatory plus a resident who recently passed away on 7/25/2022 was also nonambulatory. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2022
Plan of Correction
1
2
3
4
The administrator shall review the cited section and shall self-certify to adhere to the regulations. The administrator shall conduct an in -service training to all staff on this section of Title 22. The administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ga.gov by the POC due date, 8/2/2022.

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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3