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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603472
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:34:40 PM

Document Has Been Signed on 08/01/2024 02:34 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
GREATER LA AC/SC, 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:
08/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Darcy Farais – Area DirectorTIME VISIT/
INSPECTION COMPLETED:
02:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit regarding a deficiency discovered during the investigation of complaint control number 28-AS-20240725101705. LPA met with Darcy Farais (Program Director) and explained the reason for the visit.

LPA Mora observed bed rails on C1's bed, but the facility did not have a doctor's order for the bed rails.

The deficiency cited is documented on the LIC809-D. Exit interview held and a copy of the report and appeal was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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 2
Document Has Been Signed on 08/01/2024 02:34 PM - It Cannot Be Edited


Created By: Luis Mora On 08/01/2024 at 01:38 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: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2024
Section Cited
CCR
80072(a)(8)(B)

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Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (8) Not to be placed in any restraining device. Postural supports may be used under the following conditions: (B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.
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Facility is to ensure that Title 22 Section 80072 regulations are met at all times. Additionally, facility will obtain a doctor's order for C1's bed rails and submit a copy to CCLD by 08/09/2024.
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Based on observation and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility did not have a doctor's order for C1's bed rails.
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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: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024


LIC809 (FAS) - (06/04)
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