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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800100
Report Date: 11/19/2022
Date Signed: 11/19/2022 04:56:11 PM

Document Has Been Signed on 11/19/2022 04:56 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CARSON GUEST HOMEFACILITY NUMBER:
197800100
ADMINISTRATOR:RESURRECCION, CORAZONFACILITY TYPE:
740
ADDRESS:22418 CATSKILL AVENUETELEPHONE:
(310) 830-2518
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 6DATE:
11/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Cora ResurreccionTIME COMPLETED:
04:57 PM
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On 11/19/22, Licensing Program Analysts (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Cora Resurreccion and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for four (4) hospice residents. Currently, there are two (2) hospice resident in care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area.

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 110.0 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects 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 two (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable. LPAs reviewed Medication Administration Records (MAR) revealed accurate and maintained in order. The facility conducted a Fire/Safety Drill on 10/03/22. A working landline telephone remains available. The facility has a current liability insurance on effective 08/15/22 - 08/15/23.
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2022
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: CARSON GUEST HOME
FACILITY NUMBER: 197800100
VISIT DATE: 11/19/2022
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INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the resident's and staff vaccination records were conducted. The facility has a Mitigation Plan Report on file with CCLD. All staff had current (CPR/First-Aid) training certificates.

DEFICIENCY
Based on interviews, observation, and record reviews, LPA identified a staff #1 (S1) did not have a personnel requirements for the Administrator certificate, there was no evidence of a current Administrator Certificate on file with CCLD.

Deficiencies are cited on LIC 809D.

An exit interview was conducted and a copy of this report was provided to Cora Resurreccioin.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2022
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Document Has Been Signed on 11/19/2022 04:56 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/19/2022 at 04:06 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: CARSON GUEST HOME
FACILITY NUMBER: 197800100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405(a) Administrator – Qualifications and Duties. All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review of (S1) file and interview with Administrator regarding personnel requirements for the Administrator certificate, there was no evidence of a current Administrator Certificate on file with CCLD. This poses a potential health and safety risk to the residents in care.
POC Due Date: 12/05/2022
Plan of Correction
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Licensee to ensure that all Certified Administrators have evidence of training for administrator responsibilities and provide a current Administrator Certificate for all Administrator's and designated Administrator's on the LIC308 and provide proof of correction to CCLD by POC due date 12/05/22.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2022


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