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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602216
Report Date: 06/09/2021
Date Signed: 06/14/2021 04:49:02 PM

Document Has Been Signed on 06/14/2021 04:49 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
MONTERY PARK, CA 91754
FACILITY NAME:FRANCESCA'S HOMEFACILITY NUMBER:
198602216
ADMINISTRATOR:COELLO, BESSIE LFACILITY TYPE:
740
ADDRESS:20520 AVIS AVENUETELEPHONE:
(310) 292-8425
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 5DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:BESSIE COELLOTIME COMPLETED:
02:10 PM
NARRATIVE
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On 6/9/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called Administrator Bessie Coello and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) ambulatory residents, of which five (5) may be non-ambulatory, one (1) may be bedridden and an approved hospice waiver for two (2) residents. Currently, there is one (1) Hospice resident present during today’s visit and one on duty staff. There are four (4) out of five (5) residents with memory care needs.

LPA met with the House Manager Cynthia Campos and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. Licensee arrived later and joined LPA with the visit.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio in addition to the resident’s bedroom. LPA observed required postings throughout the facility. Covid-19 Infection Control and Prevention training records and in-service training on the approved mitigation plan were reviewed. An emergency contact list was reviewed.

REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: FRANCESCA'S HOME
FACILITY NUMBER: 198602216
VISIT DATE: 06/09/2021
NARRATIVE
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All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Potentially dangerous items, including sanitizers, are kept inaccessible to residents with dementia. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 118 degrees Fahrenheit. A comfortable temperature was maintained in the facility. Outside grounds were toured, and no bodies of water were observed. The First Aid kit was available. One fire extinguisher last serviced 6/24/2020 is fully charged. Operable smoke detectors in all bedrooms, hallways and common areas with carbon monoxide were observed. Knives and toxins were kept in a locked storage cabinet

Advisory Notes were issued, and Technical Assistance was provided.

LPA observed the following deficiencies:

At around 9:37 am, LPA observed a disrepair closet accessible to residents. The closet floor and ceiling have large holes and the wall has small holes.

At around 9:39 am, LPA observed nonprescription medications are not labeled.

At around 9:43 am, LPA did not observe a minimum of two-day supply of perishable and a seven-day supply of non-perishable foods.

At around 9:48 am, LPA observed items in the sideyard and backyard that are potential hazards to residents.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Administrator Bessie Coello.

An exit interview was conducted, and a copy of this report was provided to Administrator Bessie Coello.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/14/2021 04:49 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 06/09/2021 at 12:02 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
MONTERY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME
FACILITY NUMBER: 198602216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and photos taken, old chairs, mattress, a loose wooden fence and small pieces of wood are potential obstructions and hazards to residents. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2021
Plan of Correction
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Licensee agreed to remove all the obstructions and hazardous items in the backyard and sideyard of the facility by the POC due date. Licensee will email photos of the cleared open areas of the backyard and sideyard.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and photos taken, the facility does not maintain supplies of nonperishable foods for a minimum of one week and perishable food for a minimum of two days. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2021
Plan of Correction
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Licensee replished both perishable and nonperishable food supplies during the visit.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/14/2021 04:49 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 06/09/2021 at 12:02 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
MONTERY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME
FACILITY NUMBER: 198602216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, interview with the house manager and photos taken, residents' nonprescription PRN medications have physician's orders but there are no labels on the medications. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2021
Plan of Correction
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Licensee agreed to ensure all resdients' nonprescription PRN medications are labeled by the POC due date. Licensee will email LPA photos of labeled nonprescription PRN medications.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and photos taken, a closet accessible to residents is in disrepair. The closet floor and ceiling have large holes and the wall has small holes. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2021
Plan of Correction
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Licensee agreed to repair the closet wall, floor and ceiling by the POC due date. Licensee shall immediately make the closet inaccessible to residents by installing a padlock.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021


LIC809 (FAS) - (06/04)
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