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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320013
Report Date: 12/07/2022
Date Signed: 12/07/2022 03:39:18 PM

Document Has Been Signed on 12/07/2022 03:39 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:SENIOR MANOR CARE IIIFACILITY NUMBER:
198320013
ADMINISTRATOR:STEPHEN GRADNEYFACILITY TYPE:
740
ADDRESS:2423 SANTA FE AVETELEPHONE:
(310) 212-0883
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 0DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:CATHERINE ESPINOTIME COMPLETED:
11:00 AM
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On 12/7/2022, 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 Staff Catherine Espino (S1) and conducted a risk assessment. 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 met one staff (S1) but did not observe any resident during today's visit. Staff Espino confirmed the facility does not currently have any residents in care. Facility Annual Fees are current during today’s visit.

During the visit, LPA toured the facility with S1. This facility consists of four (4) resident bedrooms, three (3) bathrooms, kitchen, living room, dining area, office area, staff bedroom adjacent to the living room, shaded patio (located in the backyard), and a garage. Operable smoke detectors in bedrooms were observed except for one smoke detector in the hallway that does not have a battery and a cover. One operable carbon monoxide detector located in the hallway by the main entrance door is operable. One fire extinguisher last serviced on 4/16/2022 is located in the kitchen. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available.

There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. Potentially dangerous items are kept inaccessible to residents with dementia. The



Report Continued in LIC 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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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: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013
VISIT DATE: 12/07/2022
NARRATIVE
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first aid kit has all required supplies. Toxic chemicals are locked in a cabinet in the kitchen. The facility has a written emergency disaster plan posted in the living room. The facility is maintained at a comfortable temperature. LPA observed hot water temperature in the common bathroom measures 116.5 degrees Fahrenheit. There are working lights or lamps in each room at the time of visit. There are grab bars for each toilet and shower in the resident bathrooms. Showers have non-skid mats. A working telephone 310-212-0883 remains available.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed S1 was wearing a face covering, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

Deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in a civil penalty.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Staff Catherine Espino.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
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Document Has Been Signed on 12/07/2022 03:39 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 12/07/2022 at 01:56 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: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022

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
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Based on observation and interview, the licensee did not comply with the section cited above. LPA Lourdes Montoya observed a smoke detector in the hallway next to resident bedrooms has no cover and no battery. LPA also observed a desk in the office area next to the kitchen has a broken leg. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2022
Plan of Correction
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Staff Catherine Espino agreed to change the battery of the smoke detector in the hallway and place the cover. Espino stated she will remove and dispose the broken desk and replace it with a desk in good repair. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022


LIC809 (FAS) - (06/04)
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