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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602982
Report Date: 11/19/2021
Date Signed: 11/19/2021 07:24:21 PM

Document Has Been Signed on 11/19/2021 07:24 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
MONTEREY PARK, CA 91754
FACILITY NAME:FAMILY CONNECTED MEMORY CARE BOUTIQUEFACILITY NUMBER:
198602982
ADMINISTRATOR:SPIGLANIN, LAURENFACILITY TYPE:
740
ADDRESS:3414 WEST 226TH STREETTELEPHONE:
(310) 383-1877
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 5CENSUS: 5DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Caregiver - Lilian TejadaTIME COMPLETED:
01:00 PM
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On 11/19/2021, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with lead caregiver Lilian Tejada and explained the purpose of today’s visit. The facility is licensed to operate for five (5) elderly residents ages 60 and above. The facility is approved for five (5) non ambulatory of which two (2) can be under hospice care.

The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: three (3) resident's rooms, two (2) bathrooms, a living room area, a dining area, kitchen and an attached garage used for storage and staff breaks. There is an office area adjacent to the kitchen and there is a second refrigerator and freezer in the garage. The washer and dryer are also located in the garage.

LPA and caregiver toured the physical plant. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are two (2) fire extinguishers fully charged in the dining room area and the office area. First aid kit was available. Smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate.

Evaluation Report Continues on LIC 809-C.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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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
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY CONNECTED MEMORY CARE BOUTIQUE
FACILITY NUMBER: 198602982
VISIT DATE: 11/19/2021
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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 in common areas and restrooms. LPA observed all five (5) residents were present with three (3) staff of which one (1) was cleaning during the tour. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

An exit interview was conducted and a copy of this report was provided to lead caregiver Lilian Tejada.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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