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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602982
Report Date: 11/08/2023
Date Signed: 11/08/2023 02:57:05 PM


Document Has Been Signed on 11/08/2023 02:57 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:FAMILY CONNECTED MEMORY CARE BOUTIQUEFACILITY NUMBER:
198602982
ADMINISTRATOR:SPIGLANIN, LAURENFACILITY TYPE:
740
ADDRESS:3414 WEST 226TH STREETTELEPHONE:
(310) 383-1877
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:5CENSUS: 5DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lauren MahakianTIME COMPLETED:
03:00 PM
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On 11/08/2023, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced annual required visit using the full CAREs tool. LPA met with Licensee/Administrator, Lauren Mahakian and explained the purpose of today’s visit. We were later joined by House Manager, Kristi Simonian. The facility is licensed to operate for five (5) elderly residents ages 60 and above. The facility is approved for five (5) non ambulatory with a hospice waive for two (2) residents. There are five (5) residents residing in the facility and all five (5) residents were present during the visit.
Physical Plant/Structure The facility is a single-story home located in a residential neighborhood. The facility consists of three (3) resident rooms, two (2) bathrooms, a living room area, a dining area, kitchen and an attached garage. The ramps leading to the frond and back door have secured railings. LPA observed a table and chairs on a shaded patio in the back yard. The gates on the side of the home are equipped with an egress system. All walkways were observed clean, clear, and free of obstructions, hazards, and debris. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all bedrooms and found them to be clean and in good repair. All rooms were observed with the required furniture including a bed, dresser, nightstand, chair, and adequate storage space for resident’s personal belongings. All bed were observed with the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. Beds and bedding supplies were observed in good repair. All bedrooms were observed with adequate lighting. LPA observed an adequate supply of linens stored in a hall closet.
Bathrooms LPA observed the bathrooms to be within Tittle 22 regulations and fully operable. The showers had secured safety handrails, nonskid mats, and shower chairs. The water temperature measured 105.8- degrees and 106.1-degrees Fahrenheit. LPA observed an adequate supply of bath towel and wash clothes in good repair. LPA observed storage space for resident’s hygiene products. An additional supply was observed stored in the garage and are inaccessible to residents.

Continued on LIC809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY CONNECTED MEMORY CARE BOUTIQUE
FACILITY NUMBER: 198602982
VISIT DATE: 11/08/2023
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Kitchen The kitchen was inspected and observed to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries in good repair. LPA observed sharps secured in a locked cabinet in the kitchen. All cleaning supplies were observed secured in a locked cabinet under the kitchen sink. LPA observed a 3-day supply of perishable and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 106.7 degrees Fahrenheit.

Common Rooms LPA toured all rooms in the home. LPA observed the facility to be furnished appropriately to accommodate all residents. The facility was maintained at a comfortable temperature. All rooms were observed with ample lighting. All walkways were observed to be clean, clear, and free of obstructions and hazards.

Safety LPA observed all required signs posted throughout the facility. LPA observed two (2) fire extinguishers fully charged last serviced on 11/02/23, one in the dining room area and the other in the office area. First aid kit was fully stocked with necessary supply and a manual. Smoke/carbon monoxide detectors were operable. The last fire drill was on 10/10/23. LPA received and reviewed a copy of the Liability Insurance.

Files & Interviews LPA reviewed three (3) resident files and found they contained the required documents. LPA interviewed three (3) residents and they were happy with the care and services they receive. LPA reviewed three (3) staff files and found they contained the required documents, certification, and training. LPA interviewed two (2) Staff and they were able to explain policy, procedure, client care, and client rights.

Medication LPA observed Centrally Stored Medications stored in a locked cabinet in the kitchen. LPA reviewed the medications and MARs for three (3) residents. Resident’s MARs and medication are consistent with properly documented records.

Infection Control During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed required infection control signs posted throughout the facility. LPA observed a 90-day supply of PPEs stored in the garage.



During today’s visit LPA did not observe or cite any deficiencies.

An exit interview was conducted with House Manager, Krisit Simonian , and a copy of this report was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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