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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602202
Report Date: 08/16/2022
Date Signed: 08/16/2022 01:00:24 PM

Document Has Been Signed on 08/16/2022 01:00 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MERIDIAN HOME CAREFACILITY NUMBER:
198602202
ADMINISTRATOR:SAN AGUSTIN, JENNIFER GFACILITY TYPE:
740
ADDRESS:20526 WOOD AVENUETELEPHONE:
(310) 533-7898
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 5DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joseph Sol/Jemimah MejiaTIME COMPLETED:
12:15 PM
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On 8/16/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA Montoya called the facility, spoke with Licensee Joseph Sol and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with Staff Jemimah Mejia and explained the purpose of today’s visit. Licensee Joseph Sol arrived later and joined the visit.

The facility is licensed to operate six (6) elderly residents ages 60 and above; approved for four (4) non-ambulatory of which two (2) may be bedridden. Bedrooms #3 and #4 are approved for bedridden. The facility is approved for four (4) hospice residents and there are two (2) hospice residents present during today's visit.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA Montoya toured and inside and outside grounds of the facility with Staff Jemimah Mejia and Licensee Joseph Sol. 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 118.2 degree Fahrenheit. A comfortable temperature 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. The facility has one (1) fire extinguisher that was charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 6/15/2022. A working telephone #310-370-5939 remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MERIDIAN HOME CARE
FACILITY NUMBER: 198602202
VISIT DATE: 08/16/2022
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed a deficiency and issued a citation.

An exit interview was conducted with Staff Jemimah Mejia, and a hard copy and appeal Rights provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
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Document Has Been Signed on 08/16/2022 01:00 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 08/16/2022 at 12:22 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: MERIDIAN HOME CARE
FACILITY NUMBER: 198602202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA Montoya observed the kitchen is cluttered and kitchen cabinets are greasy. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee agreed to organize and clean the kitchen. Licensee shall submit the POC to CCLD via email to lourdes.montoya@dss.ca.gov by the 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:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


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