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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602866
Report Date: 03/26/2024
Date Signed: 03/26/2024 03:53:02 PM


Document Has Been Signed on 03/26/2024 03:53 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:SENIOR MANOR CARE IIFACILITY NUMBER:
198602866
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1851 REDONDELA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 5DATE:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Cathy Espino/StaffTIME COMPLETED:
03:52 PM
NARRATIVE
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On 3/26/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Cathy Espino/staff. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. Of which (6) may be non-ambulatory and (1) Bedridden in bedroom #3. Approved hospice waiver for (6).

The facility is a single-story structure located in a residential neighborhood. It consists of (5) bedrooms, (2 -1/2) full bathrooms, shaded back yard, front yard, laundry room in the attached garage.

LPA toured the physical plant with staff. 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 conditions. The water temperature properly measured between 105F. and 120F.: Kitchen 109.4°F, Bathroom #1:108.2°F and Bathroom #2:107.4°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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: SENIOR MANOR CARE II
FACILITY NUMBER: 198602866
VISIT DATE: 03/26/2024
NARRATIVE
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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 were observed. LPA found cleaning agents and poisons unlocked in the bathroom and kitchen. Sharps objects were locked and not accessible to residents. The kitchen was inspected and there is not sufficient perishable and non-perishable food available. All fire extinguishers were charged and were operable.

A review of (3) residents' service files, (2) staff personnel files were checked. (3) Medication Administration Records (MAR) were reviewed discrepancies were found. First AID kit was checked. Last fire disaster drill was on:2/24/2024.

LPA observed the facility's infection control practices. Liability insurance was given to LPA during the visit. Facility Annual Fees Current.

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

-Not enough perishable food for 2 days for 5 residents at the facility.

-Unlocked cleaning supplies in a bathroom and kitchen

-No internet access for resident’s use.

-Ceiling on living room peeling off (picture taken by LPA).

-No documented medication given for R#1, R#2 and R#3 for a couple of days.

-No Health screening and TB test for S#1


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Cathy Espino/staff.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2024 03:53 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: SENIOR MANOR CARE II
FACILITY NUMBER: 198602866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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
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Based on [(observation), the licensee did not comply with the section cited above in having cleaning agents unlocked in bathroom and under kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Staff removed cleaning agents to a locked area. Licensee will ensure all cleaning agents are locked at all times. As part of plan of correction, licensee will re-train all facility staff on how to keep cleaning supplies locked at all times. Licensee will send proof of training to LPA before POC due date.
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in not having enough perishable food for 2 days for 5 residents available at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Licensee will ensure facility has eanough perishable food for 2 days at all times. As part of plan of correction licensee will buy enough perisble food as soon as posible and send proof of correction 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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 03/26/2024 03:53 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: SENIOR MANOR CARE II
FACILITY NUMBER: 198602866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a TB test on file for S#1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Licensee will ensure all facility staff have a TB test on file. As plan of correction, licensee will get TB test for S#1 and send proof of correction to LPA before POC due date vial email.

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) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2024 03:53 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: SENIOR MANOR CARE II
FACILITY NUMBER: 198602866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above in having the ceiling in living room peeling off which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Licensee will ensure facility is in good repairs at all times. As part of plan of correction, Licensee will fix ceiling in living room and send proof of correction to LPA via email before POC due date.
Section Cited
Personnel Records
Deficient Practice Statement
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System generated citation error
POC Due Date:
Plan of Correction
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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) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2024 03:53 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: SENIOR MANOR CARE II
FACILITY NUMBER: 198602866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a health screening for S#1 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Licensee will ensure all staff has a health screening on file at all times. As part of plan of correction, licensee will get S#1's health screening and send copy to LPA via email before POC due date.
Type B
Section Cited
HSC
1569.319(b)
Regulations
(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having access to internet available to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Licensee will ensure all residents have access to internet and internet devices at all times. As part of plan of correction, licensee will contract internet services for resdeint's use. Proof of contratct will be sent 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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 03/26/2024 03:53 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: SENIOR MANOR CARE II
FACILITY NUMBER: 198602866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can 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: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not documenting medication given to R#1, R#2 and R#3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Licensee will ensure staff documents medication given to all residents at all times. As part of plan of correction, licensee will re-train all facility staff on how to document medication given to residents. Proof of training will be provided to LPA via email beofre POC due date.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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