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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320013
Report Date: 06/15/2021
Date Signed: 06/17/2021 10:49:31 AM

Document Has Been Signed on 06/17/2021 10:49 AM - 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
MONTERY PARK, CA 91754
FACILITY NAME:SENIOR MANOR CARE IIIFACILITY NUMBER:
198320013
ADMINISTRATOR:COTY CABRALFACILITY TYPE:
740
ADDRESS:2423 SANTA FE AVETELEPHONE:
(310) 212-0883
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 5DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ALLAINE DE LEONTIME COMPLETED:
12:15 PM
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On 6-15-2021 at 9:00 am, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called the facility, spoke with House Manager Allaine De Leon conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) non-ambulatory, of which one (1) may be bedridden. Hospice waiver for six (6) residents. LPA observed 5 residents of which one (1) is bedridden and three (3) on hospice care. Two staff are on duty during the visit.

At around 9:05 am, LPA met with House Manager Allaine De Leon and they both toured the inside and outside grounds of the facility. LPA’s temperature was checked but no symptom screening was conducted. De Leon stated facility staff screen residents, staff and guests for Covid-19 symptoms but no screening log is maintained.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance and visitors log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio in addition to the resident’s bedroom. LPA observed staff and residents maintain 6 feet physical distancing, and each staff wears a face covering.

LPA reviewed the facility’s surveillance testing records, one out of four staff tested with Covid-19 every seven days. A review of vaccination and N-95 Fit Testing records was conducted. All staff have completed the N-95 fit testing. Covid-19 Infection Control and Prevention training records and in-service training on the approved mitigation plan were reviewed. An emergency contact list was reviewed.

REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2021
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 06/17/2021 10:49 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 06/15/2021 at 11:33 AM
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
MONTERY PARK, CA 91754

FACILITY NAME: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin, and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview, the licensee did not comply with the section cited above. LPA observed fruit flies inside a kitchen cabinet where uncovered potatoes are stored and around the kitchen area. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2021
Plan of Correction
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Licensee shall clean the cabinet and ensure all fruit flies disappear.
Type B
Section Cited
CCR
87303(a)(1)
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA'sobservation and interview, the licensee did not comply with the section cited above. The kitchen ceiling, floor, walls, cabinets, counterop oven and stove top are dirty and greasy. The refrigerator is dirty inside and out. The window blinds in bedroom #5 is broken. This poses a potential health , safety or personal rights risk to persons in care.
POC Due Date: 06/21/2021
Plan of Correction
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Licensee agreed to fix or replace the broken window blinds in bedroom #5 and clean and degrease the kitchen as mentioned above by the POC due date.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2021


LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013
VISIT DATE: 06/15/2021
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The facility has four (4) out of five (5) residents with memory care needs. Staff completed the basic dementia training. Potentially dangerous items, including sanitizers, are kept inaccessible to residents with dementia.

All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Furniture in the living room are marked or separated, and 6 feet apart from each other. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 114.2 and 115.7 degrees Farenheit in both common bathrooms. A comfortable temperature was maintained in the facility. All bedrooms and living room have smoke detectors and they are all interconnected and operational. Carbon monoxide detector located and mounted in the hallway is operational.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. One fire extinguisher last serviced 8/11/2020 is fully charged.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

LPA observed the following deficiencies:


· The kitchen is dirty and greasy.
· Fruit flies were observed inside a kitchen cabinet and around the kitchen area.
· A broken white window blinds in resident bedroom #5.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to House Manager Allaine De Leon.

Advisory Notes were issued, and Technical Assistance was provided.

An exit interview was conducted, and a copy of this report was provided to House Manager Allaine De Leon.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
LIC809 (FAS) - (06/04)
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