198320317-2-8-2023-11-AS-AINZ-CNV24L-20230208160409

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320317
Report Date: 02/08/2023
Date Signed: 02/08/2023 04:04:22 PM

Document Has Been Signed on 02/08/2023 04:04 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CASA ESPERANZA		FACILITY NUMBER:	198320317
ADMINISTRATOR:	AGATEP, EVANGELINE		FACILITY TYPE:	740
ADDRESS:	1080 VIA LA PAZ		TELEPHONE:	(310) 787-7300
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY: 6		CENSUS: 0	DATE:	02/08/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Melanie Tallada		TIME COMPLETED:	04:15 PM

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On 2/8/2023 Licensing Program Manager (LPM) Eva Alvarez and Licensing Program Analysts (LPA) Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized designee Melanie Tallada
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The licensee has applied for a license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (5) non-ambulatory resident and (1) bedridden resident. The bedridden residents will reside in bedroom #3. The licensee plans to advertise for Special Care Programs for Dementia Residents.

LPM and LPA toured facility Kitchen, Dining Room, Staff Room, Living Room, (3) Bedrooms, (2) Bathrooms, Garage, Back Yard, and Patio with shade. LPM and LPA observed sufficient storage areas for kitchen supplies, linens, medications (secured) and chemicals (secured).

All required bedding is present, LPM and LPA observed top sheets, bottom sheets, bedspreads, blankets, pillowcases. Kitchen. Refrigerator(s) and freezer(s) are clean and have the capacity to store at least two (2) days of perishable foods.. There is storage for seven (7) day supply of non-perishable food. There is a sufficient amounts of tableware, tables, dishes, and utensils. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

LPM and LPA observed storage for personnel records and storage for Resident confidential information.

LPM and LPA observed emergency exiting plan and emergency phone numbers are posted. Resident Personal Rights are posted. Licensing Complaint contact information and Long Term Ombudsman contact information is posted.

Outdoor patio furniture with umbrella is located in backyard in patio area.

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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: CASA ESPERANZA	FACILITY NUMBER: 198320317
	VISIT DATE: 02/08/2023

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There is a washer and dryer present. There is a space for clean linen storage and a separate space for soiled linen.

LPM and LPA observed the following corrections needed during this visit:

KITCHEN AND DINNIG ROOM

Kitchen window screen has tear located in the right lower corner. POC: kitchen window screen will be repaired or replaced.

BEDROOMS

In Bedrooms #1,#2 and #3- LPM and LPA observed (6) beds with vinyl mattress covers that have the appearance of dirt marks present. POC: vinyl mattress covers will be clean and sanitary. CORRECTION MADE DURING VISIT 2/8/23

Bedrooms #2- LPM and LPA observed bed #1 with half-bed rails and bed #2 has full bedrails. POC: physician’s order is required for half-bed rails and full bed rails per Title 22 regulations. At this time, licensee does not have physician’s orders for bed rails. Licensee will ensure bed rails without a physician’s order are removed. CORRECTION MADE DURING VISIT 2/8/23

Bedroom #3- LPM and LPA observed bed #1 with full bedrails. POC: physician’s order is required for full bed rails per regulations. At this time, licensee does not have physician’s orders for bed rails. Licensee will ensure bed rails without a physician’s order are removed. CORRECTION MADE DURING VISIT 2/8/2023

Bedrooms #1, #2 and #3 - nightstands for each resident are not present

Bedrooms #1, #2 and #3- chairs are not present for each resident

Bedrooms #1, #2 and #3- lamps or sufficient lighting for each resident is not present

Bedrooms #1, #2 – chest of drawers are not present.

POC: Licensee shall ensure each resident is provided, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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: CASA ESPERANZA	FACILITY NUMBER: 198320317
	VISIT DATE: 02/08/2023

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BATHROOMS

Bathroom #1- mold present in caulk/sealer around bathtub. POC: Licensee shall provide a safe and healthful environment. Licensee will ensure mold is removed from bathtub caulk/sealant.

Bathroom #1- medicine cabinet has rust present on base level. POC: Licensee will ensure rust is removed from medicine cabinet

Bathroom #2 – (2) vanity cabinet doors do not close properly. POC: licensee will repair or replace cabinet doors.

Bathroom #2 – caulking/sealant around shower floor has mold present. POC: licensee will ensure mold is removed.

Bathroom #2 – caulk/sealant around bathtub has mold and rust present inside bathtub.

POC: licensee will shall ensure mold and rust is removed from bathtub.

Lightening:

Nightlights are not present where required and emergency flashlights are not working properly. POC: Licensee will ensure required lighting is present in facility.

Exit Interview conducted and copy of report given to Melanie Tallada.

COMPONENT III was not conducted as corrections are required at this time

Corrections required.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC809 (FAS) - (06/04)

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