198320133-2-22-2023-11-AS-WGIS-CPAQN4-20230222111830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320133
Report Date: 02/22/2023
Date Signed: 02/22/2023 11:18:39 AM

Document Has Been Signed on 02/22/2023 11:18 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	WELCOME HOME II		FACILITY NUMBER:	198320133
ADMINISTRATOR:	DIONISIO, ANTONIA		FACILITY TYPE:	740
ADDRESS:	3622 W. 225TH ST		TELEPHONE:	(310) 435-5820
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY: 6		CENSUS: 6	DATE:	02/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Antonia Dionisio		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/22/2023, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA met with Administrator Antonia Dionisio 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. All six (6) residents were present during the visit. Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) bathrooms, two (2) living areas, dining area, laundry room, and kitchen. Physical Plant LPA and Administrator toured the physical plant. The outside has a covered patio area with a table and chairs. There is an attached garage with access only through the garage door used for storage. There were no bodies of water on the premises. All walkways were clean, clear, and free of debris, obstructions, or hazards. All yard gates are easily accessible and open easily. Bedrooms All bedrooms were inspected. LPA observed that all bedrooms had the required furniture, including bed(s), dresser(s), nightstand(s) and chair(s). LPA observed ample lighting and storage for resident’s personal belongings. Linens LPA observed all bedding supplies were in good condition. All beds had the required linens including mattress cover, fitted sheets, blankets and comforters. Bed linens, comforters, and bath towels were adequately stocked at the time of visit, in a cupboard in the hallway. Additional linens, comforters and blankets were observed stored in resident’s closets. Bathrooms Bathrooms were found to be within Title 22 regulations and were clean and operational. The safety handrails in the bathroom and shower were securely fastened. The showers had a nonskid mat and a shower chair. LPA observed storage for personal hygiene products for residents. The water temperature measured between 112.2-degrees and 114.6-degrees Fahrenheit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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: WELCOME HOME II	FACILITY NUMBER: 198320133
	VISIT DATE: 02/22/2023

NARRATIVE

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Kitchen LPA inspected the kitchen. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All cutleries, pots and pans were in good repair. All appliances were clean and fully functioning. Cleaning products were locked in a cabinet under the sink. Sharps were locked in a drawer in the kitchen. The water temperature measured 109.3-degrees Fahrenheit. The laundry room is next to the kitchen. LPA observed additional paper goods (toilet paper, paper towels) stored in the cabinets above the washer and dryer.
Common Room In the two living room areas, LPA observed ample seating for all residents. The dining room had a large enough table and chairs to accommodate all residents. There is a fireplace in the back living room that is not used and is inaccessible to residents. All rooms and walkways had ample lighting and nightlights. All walkways were clean, clear, and free of obstructions and hazards. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit.
Medications LPA reviewed all residents centrally stored medications. Medications are stored in a secured cabinet in the dining room and are inaccessible to residents.
Files LPA reviewed four (4) of the resident’s files and found they contained the required documentation. LPA reviewed two (2) staff files and found they contained the required documentation, certification and training.
Safety LPA observed one (1) fire extinguisher, fully charged next to the kitchen. All smoke detectors and carbon monoxide were operable. The last emergency drill was on 02/10/23. The First aid kit had all the required items and a manual. There is a working landline within the facility. LPA observed all emergency information and numbers posted within the facility. There are no firearms or ammunition stored on the premises.
Infection Control During the visit, LPA observed the facility infection control practices. LPA observed screening protocols and logs for visitors, staff, and residents. There were sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings. All mandated infection control posters were posted. The facility has a 60-day supply of Personal Protective Equipment (PPEs) stored in the garage.
LPA reviewed the facilities which expires on 12/21/23.
No deficiencies were cited.
An exit interview was conducted, and a copy of this report was provided to Administrator Antonia Dionisio.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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