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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602866
Report Date: 04/08/2021
Date Signed: 04/14/2021 09:19:15 PM

Document Has Been Signed on 04/14/2021 09:19 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:SENIOR MANOR CARE IIFACILITY NUMBER:
198602866
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1851 REDONDELA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
04/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Angelique GradneyTIME COMPLETED:
05:00 PM
NARRATIVE
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On 4/8/2021 at 2:00 pm, LPA Lourdes Montoya conducted a case management visit at the above facility to issue citations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today’s visit was conducted telephonically via FaceTime with Angelique Gradney.

On 7/10/2020, Staff #1 informed LPA Montoya during a telephone interview that the kitchen window had no screen for many years. Staff #1 stated he informed the licensee about the missing window screen, but it was never fixed.

On 3/11/2021, Staff #2 informed LPA Montoya during a telephone interview that the kitchen window was left without a screen since her start date of work in September 2016. Staff #2 stated a new window screen was recently installed.

On 3/11/2021, while LPA Montoya was investigating a complaint, LPA Montoya performed a virtual tour for health and safety checks. LPA observed residents are well, the home is clean and in order, there are sufficient perishable and non-perishable food supplies, PPE and hygiene supplies were readily available to staff, and the facility has two caregivers providing care to six residents. LPA observed the kitchen window that staff #1 and Staff #2 stated had no screen for many years has now been covered with a new screen.

On 3/12/2021, during an interview with the administrator, Angelique Gradney, it was confirmed that recently a new screen had been installed in the kitchen window.

During a subsequent virtual visit on 3/12/2021, LPA checked all exit doors for auditory signal devices. LPA observed three exit doors, the main door, and two sliding doors. One of the sliding doors, which is the kitchen's sliding door, has no auditory device or other staff alert feature to monitor this exit door for residents with memory care needs. LPA checked other parts of the home such as the bathrooms, kitchen, living room, dining room, and backyard and observed no other things that present a hazard to residents.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 809-D). Appeal Rights Discussed.

Deficiencies:
Missing window screen and Missing auditory device

A telephonic exit interview was conducted with Angelique Gradney, and an electronic copy was sent via email for signature.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2021
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 04/14/2021 09:19 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/07/2021 at 04:09 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: SENIOR MANOR CARE II
FACILITY NUMBER: 198602866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2021
Section Cited
CCR
87303(c)

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87303 Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by:
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Licensee had already installed a new window screen.
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Based on LPA Montoya's observation and interview, the licensee failed to ensure the kitchen window had a screen. Staff #1 & Staff #2 stated window had been missing a screen for many years. The administrator admitted on 3/11/2021 that a new screen was recently installed in the kitchen window. This poses a potential risk to the personal rights, health and safety of residents in care.
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Type B
04/16/2021
Section Cited
CCR87705(j)

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Licensee shall install an auditory device or a staff alert feature on the kitchen sliding door. Licensee shall send a video of a working auditory to LPA Lourdes Montoya at lourdes.montoya@dss.ca.gov.
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Based on LPA Montoya's observation and interview, the licensee failed to ensure the kitchen's sliding door had an auditory device or other staff alert feature to monitor this exit door for residents with memory care needs. This poses a potential risk to the personal rights, health, and safety of residents in care.
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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: 04/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2021


LIC809 (FAS) - (06/04)
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