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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602397
Report Date: 02/03/2023
Date Signed: 02/03/2023 03:39:43 PM

Document Has Been Signed on 02/03/2023 03:39 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:OCEAN BREEZE CARE HOME, LLCFACILITY NUMBER:
198602397
ADMINISTRATOR:MACELLVEN, GREGGFACILITY TYPE:
740
ADDRESS:911 S WEYMOUTH AVETELEPHONE:
(310) 721-9667
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY: 6CENSUS: 5DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:24 AM
MET WITH:Evelyn Datu - Direct Support StaffTIME COMPLETED:
04:10 PM
NARRATIVE
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On 2/02/23, at 12:22 P.M., Licensing Program Analyst (LPA) Mario Leon conducted an unannounced required Annual visit with a primary focus on infection control. LPA was met by Evelyn Datu, Direct Support Professional (DS1) and Janice De Leon, Direct Support Professional (DS2), DS1 and LPA spoke with Gregg MacEllven, administrator (A1), who later arrived to the facility , via phone and the purpose of today’s visit was explained,

The facility is licensed to serve 6 ambulatory elderly clients, of which all may be non-ambulatory. There are currently (5) residents in the facility. All clients are currently ambulatory. The facility is a split-level structure located in a residential neighborhood. It consists of five (5) client bedrooms, one (1) staff room, two (2) full bathrooms, three (3) half-bathrooms, shaded back yard, front yard, laundry room and attached 2 car garage.

LPA and DSP1 toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational, yet outside of Title 22 regulations. The water temperature measured at 132.4 F in bathroom two (2). A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, as of 04/06/22, smoke detectors and Carbon Monoxide were operable.



see LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OCEAN BREEZE CARE HOME, LLC
FACILITY NUMBER: 198602397
VISIT DATE: 02/03/2023
NARRATIVE
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PINs) for any updates relating to COVID-19 guidance.

During today’s visit there were five (5) deficiencies observed, see LIC809-D. Technical assistance notes were provided, see LIC9102.

Exit interview held. A copy of the report, deficiencies, civil penalty, and appeal rights were provided to Gregg MacEllven, Direct Support Professional.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 02/03/2023 03:39 PM - It Cannot Be Edited


Created By: Mario Leon On 02/03/2023 at 01:59 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: OCEAN BREEZE CARE HOME, LLC
FACILITY NUMBER: 198602397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618


This requirement is not met as evidenced by:
(b) In addition to Section 87611(b), the licensee shall be responsible for the following:
(3) Ensuring that the use of oxygen equipment meets the following requirements:
(B)"No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.
Deficient Practice Statement
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Based on LPA's observation and interview, the licensee did not comply with the section cited above in having accepted a hospice patient, using oxygen in their private room, without any signage informing others of said usage within the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2023
Plan of Correction
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Licensee, Gregg MacEllven, shall provide evidence (photos, paperwork, etc) of the posting of necessary signage outside of resident room and on to the front of the facility via email to Mario.Leon@DSS.CA.GOV.
LPA witnessed signs on-site to be installed in front of the hospice client's room and on both entryways.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/03/2023 03:39 PM - It Cannot Be Edited


Created By: Mario Leon On 02/03/2023 at 02:12 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: OCEAN BREEZE CARE HOME, LLC
FACILITY NUMBER: 198602397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355


This requirement is not met as evidenced by:
87355 Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department
Deficient Practice Statement
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Based on LPA's observation and document verification, the licensee did not comply with the section cited above in having one staff member, Janice De Leon (Vizcara) (DSP2) to work in the facility prior to obtaining proper criminal clearance record which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Licensee, Gregg MacEllven (A1), will guarantee that DSP2 will remain off-site until her Criminal Clearance has passed and DSP2 has been associated to this facility.
A1 will submit a screenshot via Guardian showing DSP2 has acquired criminal clearance and has been associated to the facility.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/03/2023 03:39 PM - It Cannot Be Edited


Created By: Mario Leon On 02/03/2023 at 02:26 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: OCEAN BREEZE CARE HOME, LLC
FACILITY NUMBER: 198602397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in having knives left unlocked and accessible knives in the kitchen drawer. LPA also observed cleaning solutions and toxic subtsances were left under the sink as well as out in the back yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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A1 has agreed to submit video evidence of the knife lock where A1 having been added locktite on to the lock cylinder to prevent future loosening. In addition, A1 will conduct staff training regarding proper location of cleaning solutions. A1 will submit this on or prior to the POC due date to Mario.leon@DSS.CA.GOV.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 02/03/2023 03:39 PM - It Cannot Be Edited


Created By: Mario Leon On 02/03/2023 at 02:26 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: OCEAN BREEZE CARE HOME, LLC
FACILITY NUMBER: 198602397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87113
Posting of License
The license shall be posted in a prominent location in the licensed facility accessible to public view.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee (A1) did not comply with the section cited above in having certificate visible, yet in personal office space, not readily available for visitors to observe which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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A1 has agreed will provide photo evidence of accessible location via email to LPA at Mario.Leon@DSS.CA.GOV
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 02/03/2023 03:39 PM - It Cannot Be Edited


Created By: Mario Leon On 02/03/2023 at 03:22 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: OCEAN BREEZE CARE HOME, LLC
FACILITY NUMBER: 198602397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee (A1) did not comply with the section cited above in that water in bathroom two (2) was measured at 132.4 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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LPA and A1 have agreed that A1 will submit video evidence, via emal to Mario.Leon@DSS.CA.GOV, of water temperature within Title 22 regulations, as documented above, on or prior to the POC due date which is 2/06/23.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
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