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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602216
Report Date: 06/30/2021
Date Signed: 07/01/2021 09:00:56 AM

Document Has Been Signed on 07/01/2021 09:00 AM - 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:
06/30/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:CYNTHIA /BESSIE COELLOTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced case management visit for the Plan of Correction (POC). Upon arrival, LPA Montoya called the facility, spoke with the Licensee Bessie Coello and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection.

At around 10:40 am, LPA Montoya met with House Manager Cynthia Campos and they both toured the facility. LPA explained the purpose of today’s visit is to ensure that the deficiencies cited during the Annual Inspection on 6/9/2021 were corrected and in compliance with Title 22 Regulations. Licensee arrived later and joined the visit.

On 6/9/2021, LPA Montoya observed below deficiencies and Title 22 regulations were cited, Proof of Corrections (POCs) were due on 6/21/2021.

1. Section 87307(d)(4) - 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 6/14/2021.

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.

2. Section 87465(e) - 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 6/21/20. Report Continued in LIC 809C
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2021
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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Document Has Been Signed on 07/01/2021 09:00 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 06/30/2021 at 11:30 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
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME
FACILITY NUMBER: 198602216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/06/2021
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation

(a) 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:
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Licensee agreed to charge all four cameras and the ring doorbell and will submt an updated plan of operation by the POC due dtae.
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Based on LPA's observation and interview, four surveillance cameras in the common areas of the home and the Ring doorbell with a camera are not charged and not working. This poses a potential risk to residents' rights, health and safety.
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2021


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: 06/30/2021
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Licensee agreed to ensure all residents' nonprescription PRN medications are labeled by the POC due date. Licensee will email LPA photos of labeled nonprescription PRN medications.

3. Section 87303(d)(2) - 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 6/22/2021.

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.

During today’s visit, LPA Montoya observed citations on Section 87303(d)(4) and Section 87303(d)(2) have been corrected. However, LPA observed citation on Section 87465(e) has not been corrected. The POC due date was 06/21/2021. A civil penalty of $900 is assessed at $100 per day, for the period of 06/22/2021 thru 06/30/2021 beginning on the day after the Plan of Correction was due.

Based on LPA’s interview with Licensee and House Manager, all four cameras in the common areas and the ring doorbell with a camera are not charged and not currently working. This deficiency was cited under Title 22 regulations.

Exit interview conducted. A copy of the report and POC letters were provided to License Bessie Coello.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
LIC809 (FAS) - (06/04)
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