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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320013
Report Date: 06/29/2024
Date Signed: 06/29/2024 02:20:57 PM

Document Has Been Signed on 06/29/2024 02:20 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SENIOR MANOR CARE IIIFACILITY NUMBER:
198320013
ADMINISTRATOR/
DIRECTOR:		STEPHEN GRADNEYFACILITY TYPE:
740
ADDRESS:2423 SANTA FE AVETELEPHONE:
(310) 212-0883
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 6DATE:
06/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Angelique GradneyTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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On 06/29/24 at 9:13 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff and Licensee Angelique Gradney.

The facility is licensed to serve six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility has a hospice waiver approved for six (6) residents.



The facility consists of four (4) resident bedrooms, three (3) bathrooms, kitchen, living room, dining area, office area, staff bedroom adjacent to the living room, and shaded patio. The facility is clean, sanitary, and in good repair.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Residents' bedrooms had the required bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Beds and bedding were in good condition, adequate lighting provided, and walls and floors were in good repair.

Residents' bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature measured at 124 F and a hot water temperature warning sign was prominently placed. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced August 2023 was observed in the kitchen area. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013
VISIT DATE: 06/29/2024
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Licensee tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

Four (4) staff records were reviewed, 4 out of 4 staff records had required criminal record clearances or criminal record exemptions.



Five (5) resident records were reviewed and, 5 out of 5 resident records had medical assessments and pre-appraisal. Two residents’ medication was reviewed.

Deficiency was observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Based on observation and record review, staff gave expired medication to a resident.

An exit interview was conducted, plans of correction developed and reviewed, and a copy of this report and the appeals rights was discussed and left with the Licensee Angelique Gradney.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2024 02:20 PM - It Cannot Be Edited


Created By: Regina Cloyd On 06/29/2024 at 02:04 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: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
A plan for incidental medical … and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for one resident which poses/posed a potential health risk to persons in care. Staff provided Resident # 1 (R1) with two expired medications (Oxybutynin Chloride and Simvastatin). Both medications expired in 2022.
POC Due Date: 07/15/2024
Plan of Correction
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The Licensee will provide medication training to staff and new and/or current medication to R1. Licensee will send evidence of correction by the POC due date to regina.cloyd@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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024


LIC809 (FAS) - (06/04)
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