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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603026
Report Date: 11/28/2022
Date Signed: 11/29/2022 09:25:23 AM

Document Has Been Signed on 11/29/2022 09:25 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:JOEL MORALESTIME COMPLETED:
04:00 PM
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On 11/28/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. LPA Montoya conducted a risk assessment with Staff Joel Morales. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA met with Staff Joel Morales and they toured the inside and outside grounds of the facility.

The facility is licensed for six (6) non- ambulatory; approved hospice waiver for six (6) residents. LPA observed six (6) residents and 2 direct caregivers during the visit.

During the tour, LPA did not observe bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. A comfortable temperature was maintained in the facility. There are no security bars or weapons on the premises. 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, and a non-skid mat was in place. The water temperature measured at 112.0 degrees Fahrenheit. A comfortable temperature was maintained in the facility. Smoke detectors are interconnected and operational.



LPA observed the facility was found to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on August 1, 2022. A working telephone (424-731-7075) remains available.

REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUMMER BREEZE MANOR
FACILITY NUMBER: 198603026
VISIT DATE: 11/28/2022
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

Outside grounds were toured, and no bodies of water were observed. LPA observed clutters in the backyard and left side yard of the facility.

Deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Staff Joel Morales.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2022 09:25 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 11/28/2022 at 04:04 PM
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
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER BREEZE MANOR
FACILITY NUMBER: 198603026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2022

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
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Based on observation and interview, the licensee did not comply with the section cited above. LPA Lourdes Montoya observed clutters in the backyard: old/broken brown leather chair, umbrella with a stand, etc. LPA also observed clutters in the side yard of the facility: pails, dirty curtains, blanket, water jug, plastic bag, bed frame, chairs, broken rattan look chair, cardboards, boxes, etc. LPA observed broken window blinds in the living room and bathroom. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
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Administrator shall ensure the facility is clean, sanitary and in good repair. Administrator shall clean the backyard and side yard of the facility and fix or replace the window blinds in the living room and bathroom. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022


LIC809 (FAS) - (06/04)
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