198602872-12-1-2023-11-AS-LMOA-CY4VPV-20231201153721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602872
Report Date: 12/01/2023
Date Signed: 12/01/2023 03:37:28 PM

Document Has Been Signed on 12/01/2023 03:37 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:	GREAT PLACE HOME CARE		FACILITY NUMBER:	198602872
ADMINISTRATOR:	SARMIENTO, BERNADETTE		FACILITY TYPE:	740
ADDRESS:	1556 238TH STREET		TELEPHONE:	(310) 891-3349
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 6	DATE:	12/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	COTY CABRAL		TIME COMPLETED:	03:45 PM

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On 12/1/2023 at 9:30 AM, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual inspection visit to the above facility. LPA met with Caregivers Iosefo Naumati and Imelda Diquit and LPA explained the purpose of the visit. Administrator/Licensee Coty Cabral arrived later and joined the visit.

Facility is licensed to serve residents age range 60 and over, six non- ambulatory residents of which, one may be bedridden and approved hospice waiver for two residents. During this visit, there is one hospice resident.

This is a single-story home consisting of four resident bedrooms, one staff bedroom, one common bathroom, one ensuite bathroom (bedroom#5), living room, kitchen with dining area, garage, and a shaded outdoor patio.

At 9:42 AM, LPA Montoya toured the facility with Caregiver Imelda Diquit. The kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents.

At 10:30 am, outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

REPORT CONTINUED IN LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GREAT PLACE HOME CARE	FACILITY NUMBER: 198602872
	VISIT DATE: 12/01/2023

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At 10:40 am, LPA observed the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

At 11:15 am, LPA observed the smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available.

At 11:30 am, LPA conducted records review, staff files, resident files and medication administration records (MARs) are complete.

At 11:45 AM, LPA conducted interviews with staff and residents.

LPA observed the following deficiencies:

At 9:46 AM, LPA observed the filing cabinet where client files are stored has no lock.

At 10:03 AM, LPA checked the water temperature in resident bedroom #5 ensuite bathroom and it measured at 120.7 degree Fahrenheit. At 3:08 PM, LPA Montoya checked the water temperature again in the same bathroom and it measured at 124.8 degree F.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of the report and Appeal Rights were provided to Administrator Coty Cabral.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/01/2023 03:37 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: GREAT PLACE HOME CARE	FACILITY NUMBER: 198602872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(c)

(c) All information and records obrained from or regarding residents shall be confidential. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. At 9:46 AM during the inspection, LPA Montoya observed the filing cabinet where resident files are stored has no lock and files are accessible. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	Administrator agreed to intall a lock to the existing filing cabinet or purchase a new cabinet with a lock. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date 12/11/2023.

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: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/01/2023 03:37 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: GREAT PLACE HOME CARE	FACILITY NUMBER: 198602872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. At 10:03 AM, LPA checked the water temperature in the ensuite bathroom in bedroom #5 and it measured at 120.7 degree F. At 3:08 PM, LPA checked the water temperature again in the same bathroom and it measured at 124.8 degree F. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/02/2023
	Plan of Correction
1 2 3 4	Administrator shall adjust the water temperature to comply to the section above. Water temperature shall be checked and recorded every two hours for the next 24 hours. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the 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: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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