<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204998
Report Date: 07/08/2022
Date Signed: 07/08/2022 09:06:48 PM

Document Has Been Signed on 07/08/2022 09:06 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:ANZA HOME CAREFACILITY NUMBER:
198204998
ADMINISTRATOR:LEXTER SANTOSFACILITY TYPE:
740
ADDRESS:19917 ANZA AVENUETELEPHONE:
(310) 370-9613
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Shalani Ramos TIME COMPLETED:
01:43 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 07/08/22, Licensing Program Analyst (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 Shalani Ramos and explained the purpose of today’s visit. The facility is licensed to operate for (1) non-ambulatory and cleared for (5) bedridden elderly residents ages 60 and above. The facility is approved for (6) hospice residents.

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, living area, dining area, kitchen, and outside covered patio area.

LPA toured the physical plant. There were no 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 operational. The water temperature measured 111.6 F. A comfortable temperature of 64 degrees was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, 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 (1) fire extinguisher that is charged, smoke detectors operable. A working landline telephone remains available.

Evaluation Report continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
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 6
Document Has Been Signed on 07/08/2022 09:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/08/2022 at 01:31 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: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) the licensee did not comply with the section cited above in (1) carbon monoxide was not in working condition. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2022
Plan of Correction
1
2
3
4
The licensee will ensure that all emergency equipments are in working condition. The licensee will submit correction by POC date 07/09/22.

*This violation was cleared during visit.*
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above in cleaning solutions and other toxic materials under the kitchen and bathroom sinks accessible to resident in care. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2022
Plan of Correction
1
2
3
4
The licensee will ensure to adhere to Title 22 Regulation 87309 and ensure all hazadous materials are in stored in locked storage and inaccessble to residents in care. The licensee will submit correction by POC date 07/09/22.

*This violation was corrected during 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/08/2022 09:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/08/2022 at 01:31 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: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

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
1
2
3
4
Based on [(observation) the licensee did not comply with the section cited above with unsantary and uclean bathroom and kitchen areas. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
1
2
3
4
The licensee will adhere to Title 22 regulations 87303. The licensee will ensure the facility is clean and sanitized at all times. The licensee will submit correction by POC date 07/22/22.
Section Cited
Maintenance and Operation
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/08/2022 09:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/08/2022 at 01:32 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: ANZA HOME CARE
FACILITY NUMBER: 198204998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(7)
Incidental Medical and Dental Care Services
(7) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) and (record review), the licensee did not comply with the section cited above. The facility was issuing PRN without a record of dosages of medications for resident #4. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
1
2
3
4
The licensee will adhere to Title 22 Reg 87465 and ensure to maintain medication administration records for all residents. The licensee will submit correction by POC date 07/22/22.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) and (record review), the licensee has not conducted quartlery fire drills. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
1
2
3
4
The licensee will adhere to HSC 1569.695 and perform quarterly emergency drills. The licensee will submit correction by POC date 07/22/22.
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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
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: ANZA HOME CARE
FACILITY NUMBER: 198204998
VISIT DATE: 07/08/2022
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
26
27
28
29
30
31
32
DEFICIENCIES:
LPA observed at 10:32 am an unpresentable bathroom #1 and #2. At 10:40 am, LPA observed the kitchen area in an unpresentable condition. At 12:00 pm, LPA observed a non-working carbon monoxide. The facility failed to conduct fire drills on a quarterly basis. The facility did not have Medication Administration Records for resident #4 who is receiving PRN medications for July 2022.

INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were 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 staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

Deficiencies are issued and an exit interview is conducted with Shalani Ramos. A copy of this report is provided along with the appeal rights.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6