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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602982
Report Date: 11/16/2022
Date Signed: 11/17/2022 09:28:41 AM

Document Has Been Signed on 11/17/2022 09:28 AM - 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: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:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:TIME COMPLETED:
04:10 PM
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On 11/16/2022, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with Kristi Simonian 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.

Structure The facility is a single-story structure located in a residential neighborhood. The facility consists of three (3) resident rooms, two (2) bathrooms, a living room area, a dining area, kitchen and an attached garage.

Physical plant There is a ramp leading up to the front door. There is a ramp out the back door to the back yard. There are a table and chairs for the residents use. All walkways were clear and free of obstruction and debris. The gates are easy to exit with egress systems on them. There are no bodies of water or obstructions on the premises.

Bedrooms 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.
Bathrooms Bathroom 1 was in good working order. The shower had secured grab bars and nonskid mats. The water temperature measured 113.3 degrees Fahrenheit. Bathroom 2 was in good working order. Both sinks worked. The shower had secured grab bars and nonskid mats. The water temperature measured 114.2.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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: FAMILY CONNECTED MEMORY CARE BOUTIQUE
FACILITY NUMBER: 198602982
VISIT DATE: 11/16/2022
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Hygiene & Linens Storage areas for personal hygiene, cleaning supplies, and toxins were stored in the garage and not accessible to residents. Also in the garage is a supply of PPEs. An ample supply of linens is stored in the closet by the bedrooms.

Kitchen The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All appliances were in good working condition. The water temperature measured 115.2 degrees Fahrenheit.

Safety All necessary emergency numbers and signs posted. There are two (2) fire extinguishers fully charged one in the dining room area and the other in the office area. First aid kit was fully stocked with necessary supply and a manual. Smoke/carbon monoxide detectors were operable. The last fire drill was on the week October 4-11, 2022, so all staff can participate.

Files LPA reviewed four resident file, and all contained the required documentation. Three staff files were reviewed, and all contained the required documentation. A review of Medication Administration Records (MAR) was maintained in order and accurate.

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 reviewed Liability Insurance.

An exit interview was conducted, and a copy of this report was provided to Kristi Simonian.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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