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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320377
Report Date: 06/29/2024
Date Signed: 06/29/2024 07:45:12 PM

Document Has Been Signed on 06/29/2024 07:45 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:VENETIAN GARDEN GUEST HOMEFACILITY NUMBER:
198320377
ADMINISTRATOR/
DIRECTOR:		GRANETA, NORMA R.FACILITY TYPE:
740
ADDRESS:22706 MARINE AVENUETELEPHONE:
(562) 414-2853
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 6DATE:
06/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:28 AM
MET WITH:Norma GrenetaTIME VISIT/
INSPECTION COMPLETED:
12:29 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 06/29/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with licensee/administrator Norma Graneta and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents (1) may be bedridden ages 60 and above. The facility is approved for (4) hospice residents. Currently, the facility has (4) residents in hospice care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside seating area.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions 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 water temperature measured 110.7 degree F. A comfortable temperature of 78 degree F. was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, 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. Fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. A landline telephone was in working condition.
Evaluation Report Continues LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2024
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 5
Document Has Been Signed on 06/29/2024 07:45 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/29/2024 at 10:51 AM
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: VENETIAN GARDEN GUEST HOME
FACILITY NUMBER: 198320377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 above. LPA identified the facility has not conducted quarterly emergency/fire drills with staff and residents in care. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
1
2
3
4
Licensee will ensure that quarterly emergency/fire drills are conducted. Proof of correction must be sent by POC due date: 07/13/24 to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87412(b)(2)
87412 Personnel Records (b) Personnel records shall be maintained for all volunteers and shall contain the following:
(2) Health screening documents as specified in Section 87411(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section. LPA identified staff #3, #4 and #6 did not have LIC 503 Health Screening or TB test results as indicated on LIC 503. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
1
2
3
4
LIcensee will ensure that all personnel staff maintain in file an LIC 503 Health Screening with TB Test results completed for staff #3, #4 and #6. LIcensee will provide correction by POC due date: 07/13/24 to ernand.dabuet@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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/29/2024 07:45 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/29/2024 at 10:58 AM
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: VENETIAN GARDEN GUEST HOME
FACILITY NUMBER: 198320377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87415(a)(3)
87608 Postural Supports (a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section. LPA observed resident #2 with a seat belt while sitting in a wheelchair to prevent from falling over. There is no written order from a physician on record. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2024
Plan of Correction
1
2
3
4
Licensee will adhere to Title 22 Reg 87608. Licensee will read and review and provided a written statement the regulation was understood and will provide a written order from medical physician for resident #2 to utilize seat belt restraint. POC is due by 06/30/24 to ernand.dabuet@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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/29/2024 07:45 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/29/2024 at 11:24 AM
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: VENETIAN GARDEN GUEST HOME
FACILITY NUMBER: 198320377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
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 record review, the licensee did not comply with the section cited above. LPA identified staff #3, #4, and #6 did not have a current CPR/First Aid certificate completed. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
1
2
3
4
Licensee will ensure to have CPR/First Aid certification of completion for staff #3, #4, and #6 by POC due date: 07/13/24 sent to ernand.dabuet@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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: VENETIAN GARDEN GUEST HOME
FACILITY NUMBER: 198320377
VISIT DATE: 06/29/2024
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
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 the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The facility has current liability insurance on file effective 08/08/23 - 08/08/24. The facility is current on Community Care Licensing annual dues.

An audit of residents #1-#6 (R1-R6) service files and staff #1-#6 (S1-S6) personnel files revealed to be complete. Interviews were conducted with (3) residents and (3) staff during this inspection visit.

Deficiencies:
During inspection, LPA identified the facility has not conducted quarterly Emergency Drills. There is no fire drill record on file. During audit of personnel records staff #3, #4 #6 did not have Health Screening LIC 503 on file along with TB test results. Staff #3, #4 and #6 did not have current certification of completion of CPR/First Aid on file. LPA observed resident #2 sitting with postural/restraint while in a wheelchair. Audit of resident #2 records did have a written order from medical physician.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Norma Graneta and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5