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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602866
Report Date: 04/13/2022
Date Signed: 04/14/2022 03:43:18 PM


Document Has Been Signed on 04/14/2022 03:43 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: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: 4DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Charles Abad, House ManagerTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced annual required visit to the above facility. LPA met with Charles Abad, House Manager and the purpose of today’s visit was explained.

There are currently 6 residents in the facility. 1 ambulatory, 1 bedridden, and 2 non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 1/2 bathrooms, living room, kitchen, dining room/office area, shaded area, indoor and outdoor activity area, laundry room in the attached 2 car garage.

LPA and Charles 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. 1/2 bathroom has a broken sink faucet, First aid kit complete with manual; smoke detectors and carbon monoxide detector 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. 1 staff file complete. 1 resident file was complete byt medication log was missing initial for 04/08/22-04/10/22. Medication for R1 had empty medication, facility requested refill and will have medication for R#1 today. Ample supply of perishable and nonperishable food, hot water temperature is 112 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguishers are fully charged. 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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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 4


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 II
FACILITY NUMBER: 198602866
VISIT DATE: 04/13/2022
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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 was 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 once 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 deficiencies and issued a citation or citations.

An exit interview was conducted with Charles Abad, House Manager and a copy of Report and Appeal Rights provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/14/2022 03:43 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: SENIOR MANOR CARE II
FACILITY NUMBER: 198602866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87465(a)(6) - When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This was not met as evidence by: based on R#1 MARS had no initial for 3 days on R#1 medications. Observations and interviews which poses a potential risk for persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Administrator to provide training for whole staff to know the importance of initialling all medications taked and when. Also, to train staff on refillig medicine 3 to 4 days prior to medication finishing. Send copy of signatures for the whole staff in training to LPA on or before POC due date.
Section Cited
Deficient Practice Statement
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87303(e)(6) - Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This was not met as evidenced by: Based on faucet in 1/2 bathroom is broken, Observation and interviews whick poses a potential risk for persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Administrator will send a picture of fixed faucet tp LPA on or 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4