198602864-4-22-2022-11-AS-ASOO-CCQU7R-20220321152023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602864
Report Date: 03/21/2022
Date Signed: 04/22/2022 09:03:00 AM

Document Has Been Signed on 04/22/2022 09:03 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SENIOR MANOR CARE		FACILITY NUMBER:	198602864
ADMINISTRATOR:	STEVEN GRADNEY		FACILITY TYPE:	740
ADDRESS:	2011 SANTA RENA DRIVE		TELEPHONE:	(310) 989-1941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 4	DATE:	03/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Gloria Somintac, Care Giver		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA's ) Ana Soto and Jeremiah Randle conducted an unannounced Annual required visit and an infection control inspection to the above facility. LPA was met by Gloria Somintac and later spoke with Stephen Gradney via telephone and the purpose of today’s visit was explained.

There are currently (4) residents in the facility. (0) residents are ambulatory and (4) are non-ambulatory and bedridden. The facility is a single-story structure located in a residential neighborhood. It has a ramp that goes along the east and west side of the facility. The facility consists (5) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and attached garage.

LPA's and house manager toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms are clean and operational. First aid kit complete with manual; smoke detectors and carbon monoxide detector are inter-connected were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. 2 staff files were complete and current. 2 resident files were complete and current. 1 resident mars was not signed for their daily doses. 1 resident mars was complete and current Ample supply of perishable and nonperishable food, hot water temperature is 115 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguisher is fully charged on counter next to kitchen. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 03/21/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed staff and clients wearing masks, residents’ private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The facility has an approved Mitigation plan. The resident’s temperatures are checked and logged twice a day. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview conducted with Gloria Somintac, House Manager and a hard copy of report provided along with Appeal Rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/22/2022 09:03 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87465(d) -f the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: This was not met as evidence by: Based on facility did not keep up to date dosage of one the resident. Which poses a potential risk to the persons in care.
	POC Due Date: 04/05/2022
	Plan of Correction
1 2 3 4	Administrator to train staff on daily recording of medication given to residents. Administrator to provide a log of all staff signatures attending the training buy POC due date.

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) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC809 (FAS) - (06/04)

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