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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602872
Report Date: 11/24/2021
Date Signed: 11/24/2021 03:29:13 PM

Document Has Been Signed on 11/24/2021 03:29 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:GREAT PLACE HOME CAREFACILITY NUMBER:
198602872
ADMINISTRATOR:SARMIENTO, BERNADETTEFACILITY TYPE:
740
ADDRESS:1556 238TH STREETTELEPHONE:
(310) 891-3349
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: DATE:
11/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Naumati Iosefo-Lead CaregiverTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a Case Management - Deficiencies visit to document deficiencies observed annual inspection. LPA met with Naumati Iosefo-Lead Caregiver and the purpose of the visit was explained.

On 11/24/2021 LPA Cifuentes noted that medications for Resident 1 (R1) had not been administered as prescribed by doctor.

Title 22 Division 6 Chapter 1 Article 6 is being cited, please see LIC809D.

An exit interview was conducted and a plan of correction was developed. A copy of this report and appeals rights were provided to Naumati Iosefo-Lead Caregiver.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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 11/24/2021 03:29 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 11/24/2021 at 02:54 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: GREAT PLACE HOME CARE
FACILITY NUMBER: 198602872

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited
CCR
87464(f)(4)

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Basic Services
Personal assistance and care as needed by the resident... with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports
This requirement is not met as evidenced by:
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Licensee will schedule training for staff on medication adminstration and provide training outline and sign in sheet to LPA via fax or email by POC due date.
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During annual inspection on 11/24/2021 at 2:45pm LPA Cifuentes observed that medications for R1 had not been administered as prescribed. This is an immediate health and safety risk for the 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2021


LIC809 (FAS) - (06/04)
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