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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320105
Report Date: 03/21/2022
Date Signed: 03/22/2022 09:58:25 AM

Document Has Been Signed on 03/22/2022 09:58 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
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:
03/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Caregiver Ilene WilliamsTIME COMPLETED:
05:45 PM
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Licensing Program Analysts (LPA) Martessa Brown conducted an unannounced case management visit at the facility and met with Caregiver and later was met by Jehn Dema, Manager and discuss the purpose for todays visit.

During the Annual Inspection visit that was conducted on 3/18/22, LPA observe residents in rooms #2 and #3 were bedridden. On 3/21/22 LPA returned to the facility and conducted a interview with resident #1 in room #3. R1 stated was unable transfer from bed to wheelchair/walker and unable to reposition self without assistance. R1 also stated shares a room with R2 and is also bedridden. LPA could not interview R2 due to resident being in the hospital. LPA reviewed residents #1-5 physicians reports and Appraisal reports. Resident #2 physicians report indicated is bedridden. The facility is approved to retain one bedridden resident in room to which the ambulatory status has been determine by a physician. Residents in room #3 are bedridden.

The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division (6) and Chapter (8) on the attached LIC 809D. Appeal rights given.

Exit interview conducted and report was given to Jehn Dema.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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Document Has Been Signed on 03/22/2022 09:58 AM - It Cannot Be Edited


Created By: Martessa Brown On 03/21/2022 at 05:15 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: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/22/2022
Section Cited
CCR
87202(a)(2)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department. or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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The Licensee/Administrator will immediately notify the fire Marshal residents not approved for a fire clearance and will submit a plan on how he would correct. Also administrator submit LIC 200 and facility sketch(identify the location for bedridden residents) to the licensing department immediately and/or by the next business day.
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This evidence has not been met as required by: the facility license was approved to retained 1 bedridden resident and currently LPA observed there to be 2 bedridden residents (room 3 ) based on interview with resident R2 in room #2 and physicians report for R3 which is also in room #2. This poses a health and safety risk. immediate civil penalty will be assessed**.
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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: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022


LIC809 (FAS) - (06/04)
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