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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603041
Report Date: 04/06/2022
Date Signed: 04/07/2022 10:49:18 AM

Document Has Been Signed on 04/07/2022 10:49 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:LOURDES HOME 2FACILITY NUMBER:
198603041
ADMINISTRATOR:RODRIGUEZ, GEMMA SIAFACILITY TYPE:
735
ADDRESS:22133 HANSOM AVETELEPHONE:
(310) 513-1806
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gemma Sia Rodriquez TIME COMPLETED:
11:29 AM
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On 04/06/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with licensee and administrator Gemma Sia Rodriquez.. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory ages 18 through 59. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115.3 degrees F. A comfortable temperature of 71 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The last fire drill was performed on 03/15/22. A working landline phone is available.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: LOURDES HOME 2
FACILITY NUMBER: 198603041
VISIT DATE: 04/06/2022
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DEFICIENCY:
LPA observed client #1 (C1) was in bed with rails that extended from head to toe (full rails). Administrator unable to provide a physician's order on file to give a reason for a client is approved for the postural support. The client is currently not on hospice care.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, 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. A review of staff and resident temperature logs and COVID vaccinations were conducted.. The facility has an approved Mitigation Plan approved by CCLD.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

Deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Gemma Sia Rodriquez.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2022 10:49 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/07/2022 at 10:28 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: LOURDES HOME 2
FACILITY NUMBER: 198603041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [one] (client)] [identifiied with postural support (full bed rails) with no physician's order on file or on hospic care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 80072 and obtain a written physician's order for full bed rails for client #1. The licensee will provide written request for an exception to CCLD. This violation will need to be corrected by POC date: 04/20/22.
Type B
Section Cited
CCR
80072(a)(8)(E)1
Personal Rights
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [one] client #1] who had postural support (full bed rails) with no physicians authorization and is not on hospic care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 80072 and obtain a written physician's order for full bed rails for client #1. The licensee will provide written request for an exception to CCLD. The licensee will remove bed rails to correct this violation until a written physcian's order is in place. This violation will need to be corrected by POC date: 04/20/22.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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