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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603042
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:48:40 PM


Document Has Been Signed on 02/01/2024 12:48 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:LOURDES HOME 3FACILITY NUMBER:
198603042
ADMINISTRATOR:SIA, LOURDESFACILITY TYPE:
740
ADDRESS:110 E 229TH PLTELEPHONE:
(310) 549-1208
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:4CENSUS: 4DATE:
02/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gemma Sia RodridquezTIME COMPLETED:
12:51 PM
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On 02/01/24 Licensing Program Analysts (LPAs) Ernand Dabuet and Sparkle Day conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Gemma Sia Rodriquez . LPAs explained the purpose of today’s visit. The facility is licensed to operate for two (2) ambulatory and (2) non-ambulatory elderly adults ages 60 and above. The facility is approved for one (1) hospice waiver. 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) clients' rooms, one (1) staff room, two (2) bathrooms, a living area, a dining area, a kitchen, an activity room, and an outside patio area.

LPAs 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, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 105.7 degrees F. A comfortable temperature was maintained in the facility.

LPAs observed the facility to be sanitary and appropriately furnished during the 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 and maintained adequately. The fire extinguishers were charged, and 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 facility conducted Fire/Safety Drill on 01/01/24. The facility has a working landline telephone. The staff had all current CPR/First Aid Training on file. The facility has current liability insurance effective 03/01/23 - 03/01/24.
Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LOURDES HOME 3
FACILITY NUMBER: 198603042
VISIT DATE: 02/01/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted.

An audit of residents #1-#4 (R1-R4) service records and staff #1-#4 (S1-S4) personnel records revealed to be complete. Interviews conducted with (2) staff. Interviews were not available for residents during this visit. A review of client's P&I found to be maintained in order and accurate. The facility has a current surety bond coverage. The facility is current on CCL annual dues.

No deficiencies cited during this inspection visit.

An exit interview conducted with Gemma Sia Rodriquez and a copy of the report is provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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