198603005-11-27-2023-11-AS-SLEO-CXYUFX-20231127143327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603005
Report Date: 11/27/2023
Date Signed: 11/27/2023 02:33:38 PM

Document Has Been Signed on 11/27/2023 02:33 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:	CHERRY BLOSSOMS ELDERCARE		FACILITY NUMBER:	198603005
ADMINISTRATOR:	GARCIA, RONEILIO		FACILITY TYPE:	740
ADDRESS:	1416 FERN AVE		TELEPHONE:	(424) 757-2323
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Charesa Reyes		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/27/2023 at around 9:10 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Cheresa Reyes. LPA explained the purpose of the visit and was accompanied by a caregiver inside and outside the facility during this inspection. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 6 can be bedridden and/or in hospice care. A total of 6 residents are currently residing in this facility, of which 4 are ambulatory and 2 are non-ambulatory residents. The Annual Licensing Fees are current. The facility is a single-story structure located in a residential neighborhood. The home consists of the following: 6 resident bedrooms, 3 bathrooms, 1 living/dining/kitchen room area, 1 garage, 1 backyard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. LPA observed an opened cable box with exposed wires on an exterior wall of the home. There are no security bars or weapons on the premises. LPA observed mildew on the garage walls.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHERRY BLOSSOMS ELDERCARE	FACILITY NUMBER: 198603005
	VISIT DATE: 11/27/2023

NARRATIVE

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LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed unlocked cabinets with knives, cleaning solutions, and medicine.

All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 8/16/2023. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. The fire extinguisher was last serviced on 12/07/2022 and was observed near the kitchen area.

6 out of 6 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had current First Aid Certificates, Criminal Record Clearances, Job Applications, Tuberculosis Test, Facility Trainings/Drills, and signed Employee Rights.

5 resident records were reviewed and, 5 out of 5 resident records had Admission Agreements, Medical Assessments, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights.

Deficiencies are being cited based on LPA observations in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding facility being in good repair and dangerous materials/solutions shall be inaccessible to residents with dementia.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/27/2023 02:33 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHERRY BLOSSOMS ELDERCARE	FACILITY NUMBER: 198603005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2024
	Plan of Correction
1 2 3 4	Licensee will: remove mildew on the garage walls and mold one kitchen cabinet, fix the opened electric cable box, and replace the kitchen hood vent filters. Licesee will email proof of correction to socorro.leandro@dss.ca.gov.

Type B

Section Cited

CCR

87705(f)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in unlocked cabinets containing cleaning solutions, knives, and medicine, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2024
	Plan of Correction
1 2 3 4	Caregiver locked away potential hazards for residents with dementia. Licensee will fix broken cabinet lock and will provide their staff with a one hour training regarding storing potential hazards to residents with dementia. Proof of correction will be emailed to socorro.leandro@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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