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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320203
Report Date: 12/10/2022
Date Signed: 12/11/2022 09:15:50 AM

Document Has Been Signed on 12/11/2022 09:15 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: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: 5DATE:
12/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Kadiguia LinayaoTIME COMPLETED:
12:47 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 12/10/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Kadiguia Linayao and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly non-ambulatory adults of which one (1) may be bedridden. The facility is approved for two (2) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) resident's rooms, three (3) common bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area.

LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. 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 hot water temperature was tested at 112.1 F. A comfortable temperature of 71 degrees was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has several fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable. The facility conducted a Fire/Safety Drill on 11/23/22. A working landline telephone remains available. The facility has a current liability insurance effective 05/01/22 - 05/01/23. A reviewed of Medication Administration Records (MAR) was found to be maintain in order accurate.
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2022
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
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: ADORABLE REDBEAM HOME
FACILITY NUMBER: 198320203
VISIT DATE: 12/10/2022
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
INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the resident's and staff's vaccination records was conducted. The facility has a Mitigation Plan Report on file with CCLD and an Infection Control Plan.

DEFICIENCY:
Based on record reviews, LPA identified staff #6 and staff #7 (S6-S7) did not have a current CPR/First Aid Certificate on file.

The facility currently has (3) hospice residents and the facility is only approved for (2) hospice resident. The facility submitted a hospice waiver increase in 05/11/22. The hospice waiver is pending with CCLD.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

Deficiency are issued and an exit interview is conducted with Kadiguia Linayao. A copy of this report, appeal rights, and civil penalty were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 12/11/2022 09:15 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/10/2022 at 12:07 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: 12/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87411(c)
87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation) (record review), the licensee did not comply with the section cited. LPA identified staff #6 and staff #7 did not have current CPR First Aid. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2022
Plan of Correction
1
2
3
4
Licensee will ensure to adhere to Title 22 87411 and obtain CPR/First Aid for staff #6 and staff #7.
Proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 12/27.22.
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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3