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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204907
Report Date: 08/09/2022
Date Signed: 08/09/2022 06:44:00 PM

Document Has Been Signed on 08/09/2022 06:44 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GREEN MEADOWS BOARD AND CARE 11FACILITY NUMBER:
198204907
ADMINISTRATOR:ELLEN CASTILLOFACILITY TYPE:
740
ADDRESS:1595 OAKHORNE DRIVETELEPHONE:
(310) 325-8883
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 4DATE:
08/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Caregivers - Armando Erni and Radmar VistarTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Don Senaha did a Case Management for deficiencies cited during the 2022 annual visit on 8/9/2022.

LPA cited the facility on this case management for postural support due to full bed rails of resident (R1) bed and disrepair of sliding screen door for room #4 a shared room between resident (R3-R4). See attached 809D page.

Note, Licensee/Administrator out of the country during this annual visit per both caregivers.

LPA explained to both caregivers the infection control using the care inspection tool. LPA to send Licensee Ellen Castillo an email with a recap of the visit.

An exit interview was conducted and a copy of this report was provided to caregiver Armando Erni.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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 2
Document Has Been Signed on 08/09/2022 06:44 PM - It Cannot Be Edited


Created By: Don Senaha On 08/09/2022 at 12:57 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: GREEN MEADOWS BOARD AND CARE 11
FACILITY NUMBER: 198204907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
87608(a)(5)(B)

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87608(a) Based on the individual's preadmission appraisal...(5) Under no circumstances shall postural supports...limiting the use of resident's hands and feet. (B) Bedrails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care...
This requirement is not met as evidence by:
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Licensee to remove full bed rails and show proof by POC due date of 09/06/22.
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Based on observation by the LPA, R1 bed had full bed rails which poses a potential health and safety risk to persons in care.

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Type B
09/06/2022
Section Cited
CCR87307(d)(2)

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87307(d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidence by:
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Licensee to replace screen and send video proof by POC due date of 09/06/22.
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Based on observation by the LPA, room #4 had a broken sliding screen door which was detached and unusable.
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2