198602216-7-16-2021-11-AS-LMOA-C4YLZB-20210716091139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602216
Report Date: 07/14/2021
Date Signed: 07/16/2021 09:11:46 AM

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
MONTERY PARK, CA 91754

FACILITY NAME:	FRANCESCA'S HOME		FACILITY NUMBER:	198602216
ADMINISTRATOR:	COELLO, BESSIE L		FACILITY TYPE:	740
ADDRESS:	20520 AVIS AVENUE		TELEPHONE:	(310) 292-8425
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	07/14/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	BESSIE COELLO		TIME COMPLETED:	03:30 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 7/14/2021 at 2:00 pm, Licensing Program Analyst (LPA) Lourdes Montoya and Licensing Program Manager (LPM) Angela Kendrick conducted an unannounced case management visit for the Plan of Correction (POC). Upon arrival, LPA Montoya called the facility, spoke with the Licensee Bessie Coello, and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. At around 2:09 pm, LPA Montoya and LPM Kendrick met with House Manager Cynthia Campos, and waited for the licensee. LPA explained the purpose of today’s visit is to ensure that the deficiencies cited during the Annual Inspection on 6/9/2021 and subsequent POC visit on 6/30/2021 were corrected and complied with Title 22 Regulations. Licensee arrived later and joined the visit. On 6/9/2021, LPA Montoya cited the facility for the following deficiency under Section 87465(e): LPA's observation, interview with the house manager, and photos taken indicate residents' Over the Counter (OTC) and PRN medications have physician's orders, but there are no labels on the medications. The POC was due on 6/21/2021. LPA Montoya conducted a POC visit on 6/30/2021 and found that the licensee failed to correct the deficiency. LPA observed the following OTC medications don’t have pharmacy labels: *Continued in LIC 809C*

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME	FACILITY NUMBER: 198602216
	VISIT DATE: 07/14/2021

NARRATIVE

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Resident #1
1. CVS D3 25 mcg
2. GoodSense Aspirin 81 mg
3. Kirkland Signature Calcium Citrate Magnesium and Zinc with Vitamin D3

Resident: #2
1. Signature Care Vitamin D3 50 mcg
2. Dr. Choice Antacid Tablets Calcium Carbonate 750 mg
3. Nature’s Bounty Fish Oil 1200 mg / 360 mg of Omega-3
4. Nature Made B12 1000 mcg
5. Major Acetaminophen tablets 325 mg
6. Signature Care Aspirin 81 mg

Resident:#3
1. CVS Health Stool Softener Docusate Sodium 50 mg
2. Kirkland Signature D3 50 mcg
3. Tylenol

Resident: #4
1. Tylenol 500 mg

Resident: #5
1. Nature Made B12 1000 mcg

Continued in LIC 809C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME	FACILITY NUMBER: 198602216
	VISIT DATE: 07/14/2021

NARRATIVE

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During today’s visit, Licensee informed LPA Montoya and LPM Kendrick that she is working on her appeal and will be sending it within 15 business days from the citation date. LPM Kendrick reviewed the MAR and medications of R#1.

LPA reviewed the facility's Plan of Operation and provided a copy of facility's medication policy to the licensee during today’s visit.

Licensee informed LPM Kendrick that the use of surveillance cameras are included in the Plan of Operation since the issuance of the facility license.

Exit interview conducted and a copy of this report was provided to the Administrator Bessie Coello.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC809 (FAS) - (06/04)

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