198602866-3-13-2023-11-AS-ASOO-CPVLYC-20230313091008

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602866
Report Date: 02/27/2023
Date Signed: 03/13/2023 09:10:28 AM

Document Has Been Signed on 03/13/2023 09:10 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 II		FACILITY NUMBER:	198602866
ADMINISTRATOR:	GRADNEY, ANGELIQUE		FACILITY TYPE:	740
ADDRESS:	1851 REDONDELA DRIVE		TELEPHONE:	(310) 989-1941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 5	DATE:	02/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Norma Apresto, House Manager		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Norma Apesto, House Manager and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (1) residents are ambulatory, (3) are non-ambulatory, (1) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (5) bedrooms, (2 -1/2) full bathrooms, shaded back yard, front yard, laundry room in the attached garage.

LPA and Norma toured the entire inside of facility. 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 have grab bars and non-skid mats and are clean and operational included 1/2 bathroom. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap and (No-paper towels)are in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) (No- trash cans with lids in all bathrooms,) (No-cart for PPE’s), (No - mitigation plan posted and/or in folder,) (No - Fit testing completed for staff,) and required postings throughout the facility. Visitor designated area, facility has internet & IPHONE for residents to use, resident’s temperatures are checked and logged (once a day). (No- Emergency plan updated and/or posted); PPE's are enough for 30 days. All residents and staff are vaccinated and boosted

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

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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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: 02/27/2023

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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisory (TA) were issued.

1. No fit testing completed for staff

2. No paper towels in 1/2 bathroom.

3. No trash can with lid in 1/2 bathroom.

4. No cart for PPE's.

5. No mitigation plan posted and/or in binder.

6. No emergency Plan posted and/or in binder.

An exit interview conducted with Norma Apresto, House Manager and a hard copy of report provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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