198602377-5-22-2021-11-AS-LMOA-C39QM9-20210522121709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602377
Report Date: 05/18/2021
Date Signed: 05/22/2021 12:18:22 PM

Document Has Been Signed on 05/22/2021 12:18 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:	FAMILY CONNECT MEMORY CARE INC		FACILITY NUMBER:	198602377
ADMINISTRATOR:	SPIGLANIN, LAUREN MAHAKIAN		FACILITY TYPE:	740
ADDRESS:	1747 GREENWOOD AVENUE		TELEPHONE:	(310) 383-1877
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 6		CENSUS: 6	DATE:	05/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Lauren Spiglanin Mahakian/Mary Lou Giebel		TIME COMPLETED:	02:30 PM

NARRATIVE

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On 5/18/21, Licensing Program Analyst (LPA) Lourdes Montoya and LPA Troy Agard 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 Licensee Lauren Spiglanin Mahakian and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection.

LPAs were greeted by the licensee who also granted them access to the facility. The Director of Care Mary Lou Giebel later joined and assisted LPAs with the visit. LPAs were properly equipped with Fit tested N-95 and gloves.

The facility is licensed for six (6) ambulatory residents, of which one (1) may be non-ambulatory and an approved hospice waiver for three (3) residents. Currently, there are two (2) Hospice residents present during today’s visit.

The facility has an approved mitigation plan report. During the tour, LPAs observed the facility’s infection control practices. LPAs 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 all staff, 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 staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.

The facility has six (6) out of six (6) residents with memory care needs. Staff completed basic dementia training. Potentially dangerous items, including sanitizers, are kept inaccessible to residents with dementia.

All rooms were inspected. Beds in a shared bedroom are 3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

REPORT CONTINUED IN LIC 809-C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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 05/22/2021 12:18 PM - It Cannot Be Edited

Created By: Lourdes Montoya On 05/18/2021 at 12:28 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: FAMILY CONNECT MEMORY CARE INC	FACILITY NUMBER: 198602377
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in maintaining a supply of nonperishable for a minimum of one wek, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2021
	Plan of Correction
1 2 3 4	Licensee agreed to replenish the facility's nonperishable supply by May 21, 2021and maintain a minimum of one week supply.

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:

Angela J Kendrick

LICENSING EVALUATOR NAME:

Lourdes Montoya

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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: FAMILY CONNECT MEMORY CARE INC	FACILITY NUMBER: 198602377
	VISIT DATE: 05/18/2021

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Furniture in the living room are separated, and 6 feet apart from each other. 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 110.0 F. A comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and insufficient supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. Two fire extinguishers were last serviced on 10/7/2020.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; LPAs observed an obstruction on the doorway lip of an enclosed gabebo.

Advisory notes were issued and technical assistance was provided:

A deficiency was 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 Director of Care, Mary Lou Giebel.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

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