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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602202
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:28:13 PM

Document Has Been Signed on 12/11/2024 01:28 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MERIDIAN HOME CAREFACILITY NUMBER:
198602202
ADMINISTRATOR/
DIRECTOR:		SAN AGUSTIN, JENNIFER GFACILITY TYPE:
740
ADDRESS:20526 WOOD AVENUETELEPHONE:
(310) 533-7898
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 6DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Joseph SolTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 12/11/2024 around 9:30 AM, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator/Licensee, Joseph Sol. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection.

This facility is licensed to serve 6 adults ages 55 and above, of which 4 may be non-ambulatory and 2 maybe bedridden. The facility has a hospice waiver for 4 residents.

A total of 6 residents are currently residing in this facility.

The Annual Licensing Fees are current.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MERIDIAN HOME CARE
FACILITY NUMBER: 198602202
VISIT DATE: 12/11/2024
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Facility Layout: The facility is a one-story house located in a residential street. The home consists of 6 resident bedrooms, 4 full bathrooms, 1 living room area with 2 office spaces, 1 kitchen area, 1 dinning room area, 1 attached garage with a laundry area, storage, and staff break area, and 1 backyard patio area with shaded seating.

Outside Grounds: were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Resident Bedrooms: 5 out 6 of resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.

Bathrooms: Toilets, showers and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents.

Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is fire extinguisher in the hallway next to the kitchen area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MERIDIAN HOME CARE
FACILITY NUMBER: 198602202
VISIT DATE: 12/11/2024
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Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Medication Administration Records (MAR) are current and up to date.

Living Room/Community Indoor Space: There is a telephone, videoconferencing device, games (i.e. bingo) for residents in the living room area. There are couches and chairs for residents to sit at.

Miscellaneous: Documents are posted as mandated. Last drill was conducted on 9/1/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is plenty of linen and cleaning supplies.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
5 resident records were reviewed and, 5 out of 5 resident records had required documentation.

No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted and a copy of this report was left with the Licensee.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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