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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320203
Report Date: 10/30/2021
Date Signed: 10/30/2021 09:34:25 PM

Document Has Been Signed on 10/30/2021 09:34 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:ADORABLE REDBEAM HOMEFACILITY NUMBER:
198320203
ADMINISTRATOR:LINAYAO, KADIGUIA O.FACILITY TYPE:
740
ADDRESS:22521 REDBEAM AVE.TELEPHONE:
(424) 777-8707
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 3DATE:
10/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kadiguia LinayaoTIME COMPLETED:
04:15 PM
NARRATIVE
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On 10/30/21, at 1:30 pm, Regional Manager (RM)/Benita Yates, Licensing Program Manager (LPM)/ Eva Alvarez and Licensing Program Analyst/ Susan Campos, conducted a case management visit, per request of the Administrator/ Licensee Kadiguia Linayao, to relocate, on 10/30/21, three Adorable Redbeam Home facility residents, to other, designated licensed assisted living care facilities. RM Yates and LPM Alvarez were allowed entry into the facility by Luz Parites, caregiver, and upon entry RM Yates, and LPM Alvarez explained to Ms. Parites, the purpose of the case management visit. LPM Alvarez conducted, a health and safety check of the four bedrooms and three bathroom facility, and also inspected the food supply. In addition, Ms. Alvarez inspected the facilities' infection control plan, upon entry into the facility. At 2:10 pm, Administrator/ Licensee Kadiguia Linayao, arrived at the facility. Ms. Linayao, informed RM Yates, and LPM Alvarez that, as a result, of the facilities' staff shortage, the facility, at this time, would not be able to care for the three facility residents, and that they would be relocated, on 10/30/21, to other designated RCFE facilities. Ms. Yates informed Administrator/ Licensee Ms. Linayao, that she would need to submit, a staff schedule report plan, to DSS-CCL, prior to admission, of new residents to the Adorable Redbeam Home facility.

On 10/30/21, at 1:30 pm, LPM Yates observed an inoperable para transit bus parked, in the facility's driveway, and also observed that currently, the bus interior, was being used as a storage area.

On 10/30/21, at 2:10 pm, LPM Yates observed, on top of the facility's dining room table, a pair of scissors, while also observing, a resident sitting, on the same table, having lunch. In addition, Ms. Yates observed, a pill case container, in S2's unlocked walker storage.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted and a copy of the appeal rights were given to Administrator/ Licensee Kadiauia Linayao at the time of the visit.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2021
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 3
Document Has Been Signed on 10/30/2021 09:34 PM - It Cannot Be Edited


Created By: Susan Campos On 10/30/2021 at 03:00 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: ADORABLE REDBEAM HOME
FACILITY NUMBER: 198320203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2021
Section Cited
CCR
87413(a)(1)

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87413 Personnel - Operations(a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
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Administrator will submit to DSS Licensing-LPA Senaha a staff schedule report prior to the admission of any new residents to the Adorable Redbeam Home facility.
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Based on interview, observation, and record review the licensee failed to ensure the safety of the residents, RM Yates was informed on 10/30/21, at 10:46am, by a text, from individual on behalf of the Administrator, that facility did not have sufficient staff, to care for three residents, and would be relocating the residents to other RCFE facilities which posed a health risk to residents in care.
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Type A
10/30/2021
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia...(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Administrator was informed of the accessibility of the scissors, and pill box to residents, in care, and immediately removed the items from the dining table and storage walker and placed the items in a locked closet drawer.
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Based on interview, observation, and record review the licensee failed to ensure the safety of the residents, RM Yates observed on 10/30/21, at 2:10pm, scissors on top of dining table, and also, RM Yates observed a pill box in S2 walker storage which posed a health risk to residents in care.
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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:Michael Cava
LICENSING EVALUATOR NAME:Susan Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/30/2021 09:34 PM - It Cannot Be Edited


Created By: Susan Campos On 10/30/2021 at 03:53 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: ADORABLE REDBEAM HOME
FACILITY NUMBER: 198320203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2021
Section Cited
CCR
87307(a)

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87307 Personal Accommodations and Services(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
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Administrator will remove the para transit bus from the facility's driveway, and fax a photo copy of the facility drive way to LPA Senaha.

POC due date: 11/30/2021.
LPA fax number: (323) 981-1781
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Based on interview, observation, and record review the licensee failed to ensure that facility ground items are safe for the residents, on 10/30/21, RM Yates observed an inoperable para transit bus parked in the facility's drive way, and also observed, that the inside of the bus was used as storage space, which posed a potential health risk to residents in care.
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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:Michael Cava
LICENSING EVALUATOR NAME:Susan Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2021


LIC809 (FAS) - (06/04)
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