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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606934
Report Date: 05/01/2023
Date Signed: 05/02/2023 08:33:22 AM

Document Has Been Signed on 05/02/2023 08:33 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CELEBRITY CARE HOMEFACILITY NUMBER:
197606934
ADMINISTRATOR:CARMELITA M. BAUTISTAFACILITY TYPE:
740
ADDRESS:233 W. 234TH STREETTELEPHONE:
(310) 830-8366
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 5DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:CARMELITA BAUTISTATIME COMPLETED:
05:00 PM
NARRATIVE
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On 5/1/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with licensee/administrator Carmelita Bautista and explained the purpose of today’s visit. The facility is licensed to operate for four (4) non-ambulatory and two (2) bedridden elderly residents ages 60 and above. The facility is approved for (3) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) residents' bedrooms, one (1) staff bedroom with ensuite bathroom, (1) common bathroom, living area, dining area, kitchen, and outside covered patio.

LPA and licensee toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 113.1 F. A comfortable temperature of 76 degrees was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguishers that was charged, smoke detectors, and carbon monoxide were operable. LPA reviewed Medication Administration Records (MAR) revealed accurate and maintained in order. The facility conducted a Fire/Safety Drill on 4/22/2023. A working telephone (310-830-8366) remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CELEBRITY CARE HOME
FACILITY NUMBER: 197606934
VISIT DATE: 05/01/2023
NARRATIVE
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Advisory Note - Technical Assistance was issued, please see LIC9102-AN.

LPA observed the following deficiencies:

Cooking stains on Kitchen cabinets, walls, floor, and appliances; floor and counter tops are not clean; retaining wall is leaning.
Undisposed used sharps
No medical assessment for R1
No Preplacement appraisal for all five residents
Items which pose danger to residents with dementia
Incomplete resident records- no personal no SCR, No TB
Incomplete personnel records - S1 & S4
Auditory devices inoperable

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22.

Exit interview conducted. Appeal rights and a copy of this report was provided to Carmelita Bautista.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
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Document Has Been Signed on 05/02/2023 08:33 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/01/2023 at 03:05 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CELEBRITY CARE HOME
FACILITY NUMBER: 197606934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation) (interview) (record review), the licensee did not comply with the section cited above. LPA observed a knife and a pair of scissors in a drying dish rack in the kitchen readily accessible to residents with dementia. LPA observed a kitchen drawer for sharp items is open and readily accessible.This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2023
Plan of Correction
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Administrator shall put away the knife and pair of scissors in a locked storage inaccessible to residents with dementia. Administrator shall ensure the drawer for sharp items is inaccessible. Administrator corrected the deficiency during the visit.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


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Document Has Been Signed on 05/02/2023 08:33 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/01/2023 at 03:05 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CELEBRITY CARE HOME
FACILITY NUMBER: 197606934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA Montoya observed cooking oil stains in the kitchen on cabinets, walls, ceiling and appliances; LPA observed dark spots on the kitchen counter top and floor; dishwasher is not in good repair; and the eastside retaining wall is leaning towards the walkway.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Administrator shall clean the kitchen walls, ceiling, floor, counter tops and appliances, fix the diswashwer and the retaining wall. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA Montoya observed sharp objects in sharp container. Administrator stated one resident uses syringes/needles. Administrator understands that used sharps are supposed to be disposed once a week but during today's visit, administrator admitted it has been two weeks since facility disposed used sharps. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Administrator shall dispose all used sharps by the POC due date. Deficiency was corrected during the visit.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


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Document Has Been Signed on 05/02/2023 08:33 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/01/2023 at 03:05 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CELEBRITY CARE HOME
FACILITY NUMBER: 197606934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Per LPA Montoya's review of personnel records, S1 and S4 have incomplete records. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Administrator shall complete the personnel records of two staff (S1 and S4). POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observe a pre-admission appraisal conducted for all five residents. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Administrator shall complete a pre-admission appraisal to the newly admitted resident (R1) and shall maintain a preplacement appraisal record for each resident. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


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Document Has Been Signed on 05/02/2023 08:33 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/01/2023 at 03:05 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CELEBRITY CARE HOME
FACILITY NUMBER: 197606934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed auditory devices on the main door, sliding door by the kitchen and R4's bedroom are inoperable. Administrator stated the devices need new batteries. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Administrator shall install new batteries to all auditory devices and ensure they are all operable. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the 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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


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Document Has Been Signed on 05/02/2023 08:33 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/01/2023 at 04:19 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CELEBRITY CARE HOME
FACILITY NUMBER: 197606934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to ue the form LIC 602 (rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observe a documentation of medical assessment for R1 prior to admission. R1 was admitted on 4/19/2023. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Administrator shall obtain a medical assessment for R1 by the POC due date. POC shall be submitted o CCLD via email to Lourdes.montoya@dss.ca.gov/.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


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