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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603472
Report Date: 10/14/2024
Date Signed: 10/14/2024 04:23:08 PM

Document Has Been Signed on 10/14/2024 04:23 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TERN BAY HOMEFACILITY NUMBER:
198603472
ADMINISTRATOR/
DIRECTOR:		BOATNER, VERRETTAFACILITY TYPE:
735
ADDRESS:2213 TERN BAY LANETELEPHONE:
(424) 338-3054
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 3CENSUS: 2DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Assistant Administrator Ryan Reiger TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced annual visit at the facility using the CARE Tool. LPA Reyes met with Assistant Administrator Ryan Reiger 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 Reyes 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 living room 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 108 degrees F and 109.5 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 observed Client #1 (C1) was missing physician report. LPA observed the administrator certificate for Assistant Administrator Ryan Reiger that expires on 11/11/24 and Administrator Lisa Byers that expires on 6/17/26.

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: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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Document Has Been Signed on 10/14/2024 04:23 PM - It Cannot Be Edited


Created By: Tyler Reyes On 10/14/2024 at 04:10 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERN BAY HOME
FACILITY NUMBER: 198603472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

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 observation,record review, and interview with Assistant Administrator Ryan Reiger the licensee did not comply with the section cited above in Client #1 (C1) did not have a physician report on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Administrator to obtain a signed physician report for client #1 and send a copy of the client #1 physician's report to licensing by POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
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