198602397-2-14-2024-11-AS-AINZ-D2FRNL-20240214121032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602397
Report Date: 02/14/2024
Date Signed: 02/14/2024 12:10:41 PM

Document Has Been Signed on 02/14/2024 12:10 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	OCEAN BREEZE CARE HOME, LLC		FACILITY NUMBER:	198602397
ADMINISTRATOR:	MACELLVEN, GREGG		FACILITY TYPE:	740
ADDRESS:	911 S WEYMOUTH AVE		TELEPHONE:	(310) 721-9667
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	6	CENSUS: 5	DATE:	02/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Gregg Macellven/Administrator		TIME COMPLETED:	12:10 PM

NARRATIVE

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On 2/14/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Gregg Macellven/ Licensee. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above, (6) non-ambulatory. Approved hospice waiver for (2).

The facility is a split-level structure located in a residential neighborhood. It consists of five (5) client bedrooms, one (1) staff room, two (2) full bathrooms, three (3) half-bathrooms, shaded back yard, front yard, laundry room and attached 2 car garage.

LPA Iniguez toured the physical plant with an administrator. There were no bodies of water or obstructions on the premises. A total of (4) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable condition. The water temperature properly measured between: 105°F-120°F: Kitchen 109.1°F, Bathroom #1:108.7°F, Bathroom #2:109.1°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OCEAN BREEZE CARE HOME, LLC	FACILITY NUMBER: 198602397
	VISIT DATE: 02/14/2024

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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene, sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available at the properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files were reviewed. LPA checked (3) Medication Administration Records (MAR) and no discrepancies were found. The first AID kit was checked. Last facility disaster drill was: 11/7/2023.

LPA observed the facility's infection control practices. A copy of the liability insurance was given to LPA during the visit.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-No TB test for (S#2) on file.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Gregg Macellven /Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/14/2024 12:10 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OCEAN BREEZE CARE HOME, LLC	FACILITY NUMBER: 198602397
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and record review, the licensee did not comply with the section cited above in not having a TB test for S#2 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2024
	Plan of Correction
1 2 3 4	Licensee will ensure all staff have a TB test on fle. As part of plan of correction, administrator will sent proof of S#2 TB test to LPA via email before POC due date.

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 Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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