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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320105
Report Date: 03/18/2022
Date Signed: 03/18/2022 05:02:25 PM

Document Has Been Signed on 03/18/2022 05:02 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:AVIATION GUEST HOMEFACILITY NUMBER:
198320105
ADMINISTRATOR:GALLIOS, WILLIAM V. IIFACILITY TYPE:
740
ADDRESS:317 S. AVIATION BLVDTELEPHONE:
(310) 533-1131
CITY:MANHATTAN BEACHSTATE: CAZIP CODE:
90266
CAPACITY: 6CENSUS: 5DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Rosario Evangelist-House ManagerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Rosario Evangelista, House Manager and the purpose of today’s visit was explained. LPA was later met by Jehn Dema Felix-Manager. The facility is licensed to serve the Elderly Residential (RCFE) ages 60 years and above. Licensed capacity is for 6 non-ambulatory and 1 bedridden. They are approved for 4 hospice waivers.

There are currently 4 residents that were present in the facility. They have 4 bedridden residents . All The facility is a single-story structure located in a residential neighborhood on a main street. It consists of the following: 4 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor and outdoor area, laundry room and an attached garage.LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All residents rooms were checked. Beds and bedding were in good condition, adequate lighting provided. Residents rooms, walls and floors were in good repair. 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 106.9. F and 110 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

Lic 809-C is on the next page.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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: AVIATION GUEST HOME
FACILITY NUMBER: 198320105
VISIT DATE: 03/18/2022
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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 ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit deficiencies were observed. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report was provided to Jehn Dema Felix, Manager.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2022 05:02 PM - It Cannot Be Edited


Created By: Martessa Brown On 03/18/2022 at 02:32 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: AVIATION GUEST HOME
FACILITY NUMBER: 198320105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87158(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 4 residents are bedridden out of [1] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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License will request an increase on the number of bedridden residents. Licensee will review the citation and submit proof to LPA by POC due date in section 87158 (a).
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:Janae Hammond
LICENSING EVALUATOR NAME:Martessa Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
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