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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320019
Report Date: 02/09/2022
Date Signed: 02/09/2022 07:42:13 PM

Document Has Been Signed on 02/09/2022 07:42 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:A GRAND HOME CAREFACILITY NUMBER:
198320019
ADMINISTRATOR:CULALA, ETHELFACILITY TYPE:
740
ADDRESS:1132 LEVINSON STTELEPHONE:
(310) 212-7429
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 6CENSUS: 4DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Ethel Culala - LicenseeTIME COMPLETED:
04:15 PM
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On 02/09/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Ethel Culala and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly non-ambulatory residents ages 60 and above. Facility is approved for one (1) bedridden and has a hospice wavier for two (2) residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, a staff room, two (2) bathrooms, living area, dining area, office area, kitchen, laundry area between the kitchen and hallway and outside covered patio area with a table and chairs. There is an attached garage used for storage with access through the front of the garage and side of the house.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting 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 clean and operational. The water temperature measured between 108.8 F and 114.8 F in the bathroom and kitchen. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, 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. One (1) fire extinguisher was fully charged in the dining area, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate. First aid kit available near the laundry area.
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: A GRAND HOME CARE
FACILITY NUMBER: 198320019
VISIT DATE: 02/09/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents 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.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

An exit interview was conducted and a copy of this report was provided to Ethel Culala.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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