<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320133
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:02:07 PM

Document Has Been Signed on 03/12/2025 03:02 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:WELCOME HOME IIFACILITY NUMBER:
198320133
ADMINISTRATOR/
DIRECTOR:		DIONISIO, ANTONIAFACILITY TYPE:
740
ADDRESS:3622 W. 225TH STTELEPHONE:
(310) 435-5820
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 6DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:28 AM
MET WITH:Antonia Dionisio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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 03/12/2025 at 8:28am Licensing Program Analyst (LPA) Zina Brown arrived at the facility. At 8:45 am LPA entered the facility to conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. At 9:35 am, the administrator Antonia Dionisio arrived to the facility and met with LPA who discussed the purpose of the visit. Facility is licensed to serve six (6) non-ambulatory residents and an approved hospice waiver for 1 resident (in bedroom #3 only) with garage only for storage use. One (1) resident is diagnosed with (1) dementia, (1) resident is receiving hospice care services and (2) receiving home health. The facility does not handle any of the residents’ money. The facility fees are current. The facility has liability insurance with Kinsale Insurance Company (Policy # 0100278106-1) effective 01/12/2025 - 01/12/2026 with each occurrence is $1,000,000 and general aggregate is $3,000,000.

The home is a single story which consist of: (4) resident bedrooms, (2) bathroom, a living room, a family room/activity area, a kitchen with dining area, a laundry room, a garage for storage and a backyard with an outdoor shaded patio area.

Between the hours of 9:10am - 9:25 am, LPA conducted a records review of the Medication Administrator Records for (6) residents. Between hours of 9:55 am - 11:13 am, LPA conducted a records review for (6) resident records, (3) staff records and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

Between the hours of 12:15pm - 12:28pm, LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident 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, water temperature measured at 111.0F, 114.6F, and 115.9 F. The resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Report continues on LIC 809-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELCOME HOME II
FACILITY NUMBER: 198320133
VISIT DATE: 03/12/2025
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
26
27
28
29
30
31
32
Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies:

Between the hours of 9:55am - 11:13am, LPA conducted a record review and observed following:

  • NO LIC 625: Appraisal and Needs/Service Plan for Resident #1 who is diagnosed with dementia.
  • NO TB Test results on file for Administrator (A1).

An exit interview was conducted, and a copy of Report and Appeal Rights were provided.

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

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/12/2025 03:02 PM - It Cannot Be Edited


Created By: Zina Brown On 03/12/2025 at 12:46 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WELCOME HOME II
FACILITY NUMBER: 198320133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 3 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
The licensee will submit proof of TB test results for Administrator (A1) by POC due date to the department via email at zina.brown@dss.ca.gov

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:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/12/2025 03:02 PM - It Cannot Be Edited


Created By: Zina Brown On 03/12/2025 at 12:46 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WELCOME HOME II
FACILITY NUMBER: 198320133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review LPA observed no appraisal needs and service for Resident #1. Therefore the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
The licensee/administrator will submit a LIC 625: Appraisal/Needs & Service Plan for Resident #1 by the POC due date to the department via email at zina.brown@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4