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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320317
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:17:35 PM

Document Has Been Signed on 04/30/2024 02:17 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:CASA ESPERANZAFACILITY NUMBER:
198320317
ADMINISTRATOR/
DIRECTOR:		AGATEP, EVANGELINEFACILITY TYPE:
740
ADDRESS:1080 VIA LA PAZTELEPHONE:
(310) 787-7300
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY: 6CENSUS: 6DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:39 AM
MET WITH:Evangeline Agatep/LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 4/30/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Evangeline Agatep /Licensee. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above of which (6) can be non-ambulatory and (1) bedridden in bedroom #3 only. Facility has an approved hospice waiver for (2).

The facility is a single-story structure located in a residential neighborhood. It consists of (3) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room in the attached 2 car garage.

LPA Iniguez toured the physical plant with Executive Director. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected (3) rooms and (2) bathrooms. Smoke and carbon monoxide are all operable conditions. The water temperature ranged from 113.5F° – 115.2F°. The room temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CASA ESPERANZA
FACILITY NUMBER: 198320317
VISIT DATE: 04/30/2024
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Cleaning supplies, toxins, and sharps objects were stored and not accessible to residents in care. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 4/10/24.

A review of (3) residents' service files and (3) staff personnel files were maintained in order. LPA reviewed (3) Medication Administration Records (MARs) discrepancies were found.

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. All mandated inspection control posters were posted throughout the facility. Facility Annual Fess not current as 4/6/24. LPA provided PIN: 418679 to licensee. Licensee stated she will pay them later today.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Facility staff did not documented medication given for R#1, R#2, and R#3 on MARs April 2024.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Evangeline Agatep /Licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
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Document Has Been Signed on 04/30/2024 02:17 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 04/30/2024 at 01:50 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: CASA ESPERANZA
FACILITY NUMBER: 198320317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in facility staff did not documented medication given for R#1, R#2, and R#3 on MARs April 2024. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Licensee will ensure facility staff document residents MARs properly all the time. As plan of of correction licensee will re-train all facility staff on how to document properly on the residentls MARs. Licensee will sent proof of training to LPA before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


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