198603047-1-13-2024-11-AS-ARID-CZG25G-20240113160531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603047
Report Date: 01/13/2024
Date Signed: 01/13/2024 04:05:41 PM

Document Has Been Signed on 01/13/2024 04:05 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:	GREEN MEADOWS HOME II		FACILITY NUMBER:	198603047
ADMINISTRATOR:	OM, RAKSMIE		FACILITY TYPE:	735
ADDRESS:	24225 POSTMASTER AVE		TELEPHONE:	(310) 871-4219
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY: 4		CENSUS: 2	DATE:	01/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:39 PM
MET WITH:	SONDARAWATEY CHHUON		TIME COMPLETED:	04:20 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 01/13/2024, Licensing Program Analyst (LPA) conducted an unannounced annual required visit with a primary focus on infection control measures, using the new care tool. LPA was met by Sondarawatey Chhuon the staff, and the purpose of today’s visit was explained. The facility is licensed to serve 4 ambulatory residents 18 to 59 years of age. The facilities annual fees are current. As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were also observed. The facility has the mandated COVID infection control posters. My temperature was taken at the entrance of the facility where there is a sanitizing station and a logbook for visitors to check in. LPA Richard and Chhuon toured the facility. All client rooms were checked. Beds and bedding 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. LPA Richard further observed the facility to be clean and appropriately furnished at the time of visit. Bathrooms were observed to be clean and operational. LPA observed that the fire extinguisher was fully charged and there were no bodies of water on the premises. All windows and window screens were in good condition. The water temperature was within guidelines and measured 113.8 degrees Smoke/Carbon monoxide detectors were operable. The last disaster drill was completed on 12/30/23 Continued on LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

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 3

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: GREEN MEADOWS HOME II	FACILITY NUMBER: 198603047
	VISIT DATE: 01/13/2024

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

There are currently 4 residents in care. The facility is one-story structure with 4 bedrooms, 2 bathrooms, living room, kitchen, dining room, sunroom, and patio. The backyard was free from any hazards or obstructions. LPA observed that the backyard was well-maintained with different types of fruit trees and a sitting area for the residents. LPA observed that the resident/staff files were maintained in a locked filing cabinet as well as all medications. Facility had required postings for employee rights, emergency contacts, personal rights, and house rules. The facility license was posted and current. The kitchen area was checked and in compliance with title 22. Perishable and non-perishables food supply was adequate at time of visit. All disinfectants, toxins, knives, and cleaning solutions were locked and inaccessible to residents.

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 that staff were wearing face coverings and had the required postings posted throughout the facility.

During today’s visit there were two deficiencies cited.

An exit interview was held, a copy of the Facility Evaluation Report and appeal rights were provided to the staff Sondarawatey Chhuon.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/13/2024 04:05 PM - It Cannot Be Edited

Created By: Antonine Richard On 01/13/2024 at 03:45 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GREEN MEADOWS HOME II	FACILITY NUMBER: 198603047
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 4 total of staff (S1 -S2) are missining the first aid certifications on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee will submit a copy of the First Aid Certificate via email to LPA Antonine.Richard@dss.ca.gov on the POC date above. 01/30/2024

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:

Antonine Richard

LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3