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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204739
Report Date: 09/26/2023
Date Signed: 09/26/2023 12:16:34 PM

Document Has Been Signed on 09/26/2023 12:16 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:TLC GUEST HOME 1FACILITY NUMBER:
198204739
ADMINISTRATOR:TERESITA L. CASTANEDAFACILITY TYPE:
740
ADDRESS:18309 FAIRVIEW LANETELEPHONE:
(310) 819-3965
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 6DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:xTIME COMPLETED:
12:35 PM
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On 09/26/2023 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arriving at the facility, LPA met with the Administrator Muqeet Dadabhoy, who assisted with the visit. Upon arrival at the facility, LPA David España conducted a risk assessment at the front door. Based on the assessment, the facility is cleared of Covid-19 infection.

Six (6) clients and two (2) staff were present in the facility during this inspection.Facility is licensed to serve 6 non-ambulatory clients ages 60 and above, may retain six hospice residents. The home consists of six (6) resident bedrooms, five (5) bathrooms, living room, dining room, kitchen, and garage. S1 accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. LPA observed resident bathrooms and were checked.

Toilets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 105-120 F (i.e., 114.6F). Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. LPA toured the kitchen area and observed a two-day (2) supply of perishable and a seven-day (7) supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher last serviced 06/22/2022 was observed near the stove in the kitchen area. LPA tested one Smoke detector and Carbon Monoxide detector in living room area and were functional. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector units. Staff records were reviewed, 5 out of 5 staff records reviewed had current first aid certificates and had required criminal record clearances.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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 3
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: TLC GUEST HOME 1
FACILITY NUMBER: 198204739
VISIT DATE: 09/26/2023
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Clients records were reviewed, 5 out of 5 client records had Admission Agreements, Medical Assessments and Reappraisals; Preplacement Appraisal Information (LIC 603); Physicians Report (LIC 602) Medical assessment including TB test; Identification and Emergency Information (LIC 601); Consent for Medical Treatment (LIC 627C); Telecommunications Device Notification form (LIC 9158); Functional Capability Assessment (LIC 9172); Personal Rights Forms (LIC 613); and Centrally Stored Medications and Destruction Record (LIC 622) etc.

According to the California Code of Regulations (California Code of Regulations (CCR), Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, based on LPA observation, interviews conducted and record review, therefore no citations were issued at this time.

Technical Assistance:

Disaster Preparedness - Technical Assistance: 1569.695(a)(5)

An exit interview was conducted, Technical Assistance were reviewed and discused with the Licensee Muqeet Dadabhoy. A copy of this report and appeal rights were provided to the Licensee Muqeet Dadabhoy.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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