198601725-9-24-2022-11-AS-EDAT-CJKTYZ-20220924150934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601725
Report Date: 09/24/2022
Date Signed: 09/24/2022 03:10:40 PM

Document Has Been Signed on 09/24/2022 03:10 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:	A SUNNYDAY GUEST HOME		FACILITY NUMBER:	198601725
ADMINISTRATOR:	LORNA B. CASTRO		FACILITY TYPE:	740
ADDRESS:	411 W. 226TH STREET		TELEPHONE:	(424) 731-7451
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 6		CENSUS: 2	DATE:	09/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:14 PM
MET WITH:	Lorna Castro		TIME COMPLETED:	03:14 PM

NARRATIVE

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On 09/24/22, 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 Lorna Castro and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above. The facility is approved for (3) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (3) residents' rooms, (2) common bathrooms, (1) staff room, a living area, a dining area, a kitchen, and an outside patio area.

LPA toured the physical plant. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be operational. The water temperature measured 105.6 F. A comfortable temperature of 75 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharp 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 (2) fire extinguishers that are fully charged, and smoke detectors operable. A review of resident’s Medication Administration Records (MARs) and Fire Drill Test are maintained in order and accurate. The last Fire Drill was conducted on 08/26/22 at 6:00 pm. A working landline telephone remains available.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2022

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: A SUNNYDAY GUEST HOME	FACILITY NUMBER: 198601725
	VISIT DATE: 09/24/2022

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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 staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

DEFICIENCIES:

LPA identified through a review of the resident's files, that resident #1 (R1) who is diagnosed with dementia did not have a current annual medical or appraisal assessment on file. The last medical assessment (LIC 602) was on 08/27/19.

Deficiency is issued and an exit interview is conducted with Lorna Castro.

A copy of this report is provided along with the appeal rights.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2022 03:10 PM - It Cannot Be Edited

Created By: Ernand Dabuet On 09/24/2022 at 02:09 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: A SUNNYDAY GUEST HOME	FACILITY NUMBER: 198601725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(5)(A)

(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. 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 cited above. LPA identfied (R1) with dementia did not have a current medical/appraisal assessment on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2022
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 87705. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. The licensee will obtain a current physician's & appraisal assessment completed for (R1). Plan of correction will be submitted by POC due date: 10/10/22 to LPA's attention by fax 323-981-1781.

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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Ernand Dabuet

LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2022

LIC809 (FAS) - (06/04)

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