198602210-8-23-2022-11-AS-ASOO-CHKPD9-20220823111311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602210
Report Date: 08/21/2022
Date Signed: 08/23/2022 11:13:27 AM

Document Has Been Signed on 08/23/2022 11:13 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	INDIAN PEAK MANOR		FACILITY NUMBER:	198602210
ADMINISTRATOR:	TORRE, RICARDO DELA		FACILITY TYPE:	740
ADDRESS:	27102 INDIAN PEAK ROAD		TELEPHONE:	(424) 206-2292
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90274
CAPACITY:	6	CENSUS: 5	DATE:	08/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Glenda Marquez, Administrator		TIME COMPLETED:	12:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met with Glenda Marquez, Administrator and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (5) residents are ambulatory, (0) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (4) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room in the attached 2 garage.

LPA and Glenda toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Ceiling between living room and hallway has scratches, nail holes, and paint is chipped off. Kitchen cabinets uppers and lowers need cleaning and/or paint. Piece of wood missing on lower cabinets next to stove. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is 112.7 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INDIAN PEAK MANOR	FACILITY NUMBER: 198602210
	VISIT DATE: 08/21/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, no cart for PPE’s, mitigation plan posted and/or in folder, No fit testing done for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted, PPE's are enough for 30 days.

Technical Advisories (TA's) issued. FIt testing needs to be completed.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued citations.

An exit interview was conducted with Glenda Marquez, Administrator a hard copy was provided and along with Appeal Rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2022 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INDIAN PEAK MANOR	FACILITY NUMBER: 198602210
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services....... This was not as evidence by: Based on facility Ceiling between living room and hallway has scratches, nail holes, and paint is chipped off. Kitchen cabinets uppers and lowers need cleaning and/or paint. Piece of wood missing on lower cabinets next to stove. Which poses a potential health and safety risk for persons in care.
	POC Due Date: 09/05/2022
	Plan of Correction
1 2 3 4	Facility will repair and provide LPA with pictures of repairs by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4	87555(b)(29)All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This was not as evidence by: Based on Kitchen cabinets uppers and lowers need cleaning and/or paint. Piece of wood missing on lower cabinets next to stove. Which poses a potential health and safety risk for persons in care.
	POC Due Date: 09/05/2022
	Plan of Correction
1 2 3 4	Facility will repair and provide LPA with pictures of repairs by POC due date.

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2022

LIC809 (FAS) - (06/04)

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