198603042-2-2-2023-11-AS-MLEN-CNP3AF-20230202170441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603042
Report Date: 02/02/2023
Date Signed: 02/02/2023 05:07:59 PM

Document Has Been Signed on 02/02/2023 05:07 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	LOURDES HOME 3		FACILITY NUMBER:	198603042
ADMINISTRATOR:	SIA, LOURDES		FACILITY TYPE:	740
ADDRESS:	110 E 229TH PL		TELEPHONE:	(310) 549-1208
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 4		CENSUS: 4	DATE:	02/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:43 PM
MET WITH:	Gemma Sia Rodriguez, Licensee		TIME COMPLETED:	04:59 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 02/02/22, Licensing Program Analyst (LPA) 02/02/23 conducted an unannounced annual required visit with a primary focus on Infection Control. LPA met with licensee Gemma Sia Rodriquez and explained the purpose of today’s visit. The facility is licensed to operate for (2) non-ambulatory and (2) ambulatory elderly residents ages 60 and above. The facility is approved for one (1) hospice resident. The residents are Harbor Regional Center consumers. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area. LPA and licensee 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 was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be outside of Title 22 regulations yet were clean and operational. The water temperature measured 133.8 F, Title 22 regulations. A comfortable temperature of 74.6 F 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 residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has one (1) fire extinguisher that was last charged on 04/13/22, smoke detectors, and carbon monoxide were operable. LPA reviewed centrally stored medications revealed to be accurate and maintained in order. The facility conducted a Fire/Safety Drill on 01/02/22. A working landline telephone remains available. See LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LOURDES HOME 3	FACILITY NUMBER: 198603042
	VISIT DATE: 02/02/2023

NARRATIVE

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility does not have a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PINs) for any updates relating to COVID-19 guidance.

During today’s visit there was (1) deficiency observed, see LIC809-D.

Exit interview held. A copy of the report, deficiency, and appeal rights were provided to Gemma Sia Rodriguez, Licensee..

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/02/2023 05:07 PM - It Cannot Be Edited

Created By: Mario Leon On 02/02/2023 at 04:51 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: LOURDES HOME 3	FACILITY NUMBER: 198603042
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2023

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 LPA's observation, the licensee did not comply with the section cited above in that the water temperature was measured at 133.8 F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2023
	Plan of Correction
1 2 3 4	Gemma sia Rodriguez, Licensee, will submit video clip of maximum water temperature to LPA Ernand Dabeut on or prior to the POC due date which is 02/06/23.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Mario Leon

LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

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