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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603472
Report Date: 11/30/2023
Date Signed: 11/30/2023 11:53:50 AM

Document Has Been Signed on 11/30/2023 11:53 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TERN BAY HOMEFACILITY NUMBER:
198603472
ADMINISTRATOR:BOATNER, VERRETTAFACILITY TYPE:
735
ADDRESS:2213 TERN BAY LANETELEPHONE:
(424) 338-3054
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 3CENSUS: 2DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Whitley John - AdministratorTIME COMPLETED:
12:13 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Whitley John (Administrator) and explained the reason for the visit. The facility is licensed to serve 3 non-ambulatory clients ages 18-59.

A tour of the single-story facility included the 3 client bedrooms, 2 bathrooms, living room, dining area, kitchen, staff area, front yard, backyard and attached garage. LPA Mora conducted the tour with Verretta and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps and cleaning chemicals were observed locked under the kitchen sink. The First Aid kit is kept mounted on the hallway wall and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in each bedroom closet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a hallway closet. Client and staff files are kept in a hallway closet. All bedrooms have all required furniture, lighting, and bedding. The bathrooms were observed with shower mats and required grab bars for non-ambulatory clients. The water temperature was tested in the both bathrooms and measured at 119.7 degrees F and 119.5 degrees F, which is within the required 105-120 degrees F. Fire extinguishers were observed in the hallways and are fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and in each room and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for 2 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for 2 clients and 5 staff. LPA interviewed 1 client and 2 staff. LPA observed the administrator certificate for Whitley John - 6051966735 that expires on 04/18/25.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (Refer to LIC 809-D). Exit interview held and a copy the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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Document Has Been Signed on 11/30/2023 11:53 AM - It Cannot Be Edited


Created By: Luis Mora On 11/30/2023 at 11:46 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERN BAY HOME
FACILITY NUMBER: 198603472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 clients which poses/posed a potential health, safety or personal rights risk to persons in care. Both clients did not have a Physician Report (LIC 602) on file.
POC Due Date: 12/14/2023
Plan of Correction
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Licensee is to comply with Section 80069 at all times. Additionally, the Licensee will obtain a Physician Report (LIC 602) for both clients and submit a copy to CCLD by 12/14/2023.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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