<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603026
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:58:23 PM

Document Has Been Signed on 10/12/2021 03:58 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
MONTERY PARK, CA 91754
FACILITY NAME:SUMMER BREEZE MANORFACILITY NUMBER:
198603026
ADMINISTRATOR:BAUTISTA, TERESITAFACILITY TYPE:
740
ADDRESS:1558 W 216TH STTELEPHONE:
(310) 418-7938
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 6DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Joel MoralesTIME COMPLETED:
12:40 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
Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas was met by house manager/ caregiver staff, Tula Thaxter, LPA conducted a risk assessment, Based on the assessment, the facility is clear of Covid-19 infection. LPA was properly screened for Covid-19 symptoms and temperature was checked. Tula granted access and allowed LPA to enter the facility to conduct inspection. Back up Administrator, Joel Morales arrived shortly after and assisted LPA with the visit LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for 6 non-ambulatory residents and 6 hospice approved waivers. There are currently, 6 residents; three (3) residents are in hospice care.

LPA and staff Tula both toured the inside and outside grounds of the facility. The one-story residential house consists a kitchen, dining room, living room, family room, one (1) staff bedroom, four (4) resident bedrooms, two (2) bathroom, washer/dryer room, shaded backyard patio, and two (2) storage sheds.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio. LPA observed staff and residents maintain 6 feet physical distancing, and all staff wear a face covering.

All rooms were inspected. Beds in shared bedrooms are 6 feet apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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
MONTERY PARK, CA 91754
FACILITY NAME: SUMMER BREEZE MANOR
FACILITY NUMBER: 198603026
VISIT DATE: 10/12/2021
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
26
27
28
29
30
31
32
Furniture in the living room are marked or separated, and 6 feet apart from each other. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. On 10/12/21 LPA measured bathroom water temperature and observed water temperature measured at 126 degrees F. Comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage drawer. On 10/12/21 LPA observed kitchen stove burner located left back was not operable, staff turned knob and it didn’t turn on. Staff indicates burners were working earlier that morning. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. One (1)Carbon Monoxide and Smoke Detectors (connected) were tested and are in operable condition. On 10/12/21 LPA heard one smoke detector located in the livingroom area chirping as if battery was low charge. The facility has (2) Fire Extinguishers fully charged and accessible, extinguishers were serviced on March 23, 2021.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

Deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided via email to facility representative.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/12/2021 03:58 PM - It Cannot Be Edited


Created By: Jey Cardenas On 10/12/2021 at 11:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: SUMMER BREEZE MANOR
FACILITY NUMBER: 198603026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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 (41 degrees C) and not more than 120 degree F (49 degrees C).

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, On 10/12/21 LPA measured bathroom water temperatuer and observed water was at 126 degrees F, which poses an immediate health, safety risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
1
2
3
4
Joel turned water heater down at the time of visit, LPA requested staff keep a water log for seven days to ensure temperature stays within limits.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Jey Cardenas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/12/2021 03:58 PM - It Cannot Be Edited


Created By: Jey Cardenas On 10/12/2021 at 11:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: SUMMER BREEZE MANOR
FACILITY NUMBER: 198603026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

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, On 10/12/21 LPA Observed kitchen gas stove burner was inoperable, staff turned knob and left back burner didnt turn on. LPA observed smoke detector in the livingroom chirping which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
1
2
3
4
Licensee will ensure stove is serviced and burner is operable, or replace stove. Work recept to be submitted to LPA. Administrator to change battery, or replace smoke detector, send recording, or receipt of deterctor purchase. jeyde.cardenas@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date: 10/19/2021
Plan of Correction
1
2
3
4
Administrator to change battery, or replace detector to ensure its not chirping. Video recording to be submitted to LPA by POC due date, or submit receipt to LPA.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Jey Cardenas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
Page: 4 of 4