198602614-2-14-2023-11-AS-DESA-CP2W4G-20230214155732

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602614
Report Date: 02/14/2023
Date Signed: 02/14/2023 03:57:41 PM

Document Has Been Signed on 02/14/2023 03:57 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:	PRIME OPTIONS CARE INC		FACILITY NUMBER:	198602614
ADMINISTRATOR:	NGUYEN, HAI		FACILITY TYPE:	735
ADDRESS:	2041 W 162ND ST		TELEPHONE:	(310) 678-6784
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY: 5		CENSUS: 4	DATE:	02/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:18 PM
MET WITH:	Hai Nguyen		TIME COMPLETED:	04:15 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	Licensing Program Manager (LPM) Ulysses and Licensing Program Analyst (LPAs) Antonine Richard and David Espana conducted an unannounced Annual required visit with a primary focus on infection control measures. LPAs were met by Melonie Suarez House manager and the purpose of today’s visit was explained. The facility is licensed to serve 5 clients (age 18-59) of which 1 maybe non-ambulatory There are currently (4) Harbor Regional Center clients in placement. 1 client is non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room and an attached garage. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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 F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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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Document Has Been Signed on 02/14/2023 03:57 PM - It Cannot Be Edited

Created By: David Espana On 02/14/2023 at 03:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PRIME OPTIONS CARE INC	FACILITY NUMBER: 198602614
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above LPAs observed a hand shovel and a pick axe in the back yard, cleaning solutions, detergents and bleach in the garage accessible to clients in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2023
	Plan of Correction
1 2 3 4	The administrator had all sharps and toxinremoved and stored were inaccessible to residents. Administrator will create a plan of correction to ensure future compliance. Proof correction will be submited to LPA Antonine at antonine.richard@dss.ca.gov.

Type B

Section Cited

CCR

85088(c)(1)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). 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 LPAs observed 4 beds present in the facility the licensed capacity is for 5 clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2023
	Plan of Correction
1 2 3 4	The administrator agreed to place a bed in bedroom number 1. Administrator will create a plan of correction to ensure future compliance. Proof correction will be submited to LPA Antonine at antonine.richard@dss.ca.gov.

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

LICENSING EVALUATOR NAME:

David Espana

LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: PRIME OPTIONS CARE INC	FACILITY NUMBER: 198602614
	VISIT DATE: 02/14/2023

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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were deficiencies observed. Physical Plant & Environmental Safety - Type B: 80087(g) - LPAs observed a hand shovel and a pick axe in the back yard, cleaning solutions, detergents and bleach in the garage accessible to clients in care.
Physical Plant & Environmental Safety - Type B: 85088(c)(1) - LPAs observed 4 beds present in the facility which the licensed capacity is for 5 clients.

Exit interview held and plans corrections developed. A copy of the report and appeals rights was provided to Hai Nguyen, Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC809 (FAS) - (06/04)

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