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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204998
Report Date: 07/08/2022
Date Signed: 07/08/2022 09:05:14 PM

Document Has Been Signed on 07/08/2022 09:05 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Shalani Ramos TIME COMPLETED:
04:15 PM
NARRATIVE
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On 07/08/22, Licensing Program Analyst (LPA) Ernand Dabuet initiated a Case Management visit. LPA was met by Shalani Ramos the assistant administrator and explained the purpose of today’s visit.

LPA toured the physical plant in association with the required annual inspection on 07/08/22. The facility is caring for residents diagnosed with dementia and observed the residents with non-up-to-date medical assessment and reappraisal reports for residents #1- #4 (R1–R4). The physician's reports for (R1) is dated 02/05/21 and (R2) is dated 06/08//21. While (R3) and (R4) are dated 10/06/20. During the inspection, LPA observed that the facility did not have a current administrator on file and did not notify the Department of the change of administrator. During record review, an active administrator was observed for Rodrigo Ramos which is not in compliance with PIN 21-24 CCLD.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/08/2022 09:05 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/08/2022 at 03:29 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2022
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator...The administrator shall have ... other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section...
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The licensee will adhere to Title 22 Section 87405. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 07/22/22 with documentation for authorized facility administrator.
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This requirement was not met as evidenced by: Based on observation and interview, the licensee did not have an authorized administrator file with CCLD. This citation poses a potential health and safety risk to residents in care.
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Type B
08/08/2022
Section Cited
CCR87705(5)

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87705 (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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The licensee will adhere to Title 22 Section 87705. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. The licensee will ensure to obtain medical assessments/reappraisals for all residents in care. Plan of correction will be submitted by POC due date: 08/08/22.
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This requirement was not met as evidenced by: Based on observation and interview, the licensee did not have up to date medical assessments and reappraisal for (R1-R4). This citation poses a potential health and safety risk to residents in care.
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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: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)
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