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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602982
Report Date: 10/30/2024
Date Signed: 10/30/2024 12:52:12 PM

Document Has Been Signed on 10/30/2024 12:52 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:FAMILY CONNECTED MEMORY CARE BOUTIQUEFACILITY NUMBER:
198602982
ADMINISTRATOR/
DIRECTOR:		SPIGLANIN, LAURENFACILITY TYPE:
740
ADDRESS:3414 WEST 226TH STREETTELEPHONE:
(310) 383-1877
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 5CENSUS: 5DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Kristi SimonianTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 10/30/2024, the department conducted an unannounced annual visit to the facility listed above. The department met with Administrator, Kristi Simonian, and the purpose of today’s visit was explained. The facility is licensed to operate for five (5) elderly residents ages 60 and above. The facility is approved for five (5) non- ambulatory residents with an approved hospice waiver for two (2). There are five (5) residents residing in the facility and all five (5) residents were present during the visit.
Physical Plant/Structure The facility is a single-story home located in a residential neighborhood. The facility consists of three (3) resident rooms, two (2) bathrooms, living room, dining room, kitchen, office area, and an attached garage. The ramps leading to the front and back door have secured railings. The department observed a table with umbrella and chairs on a patio in the back yard. All walkways were observed clean, clear, and free of obstructions, hazards, and debris. The department did not observe any bodies of water on the premises.
Bedrooms The department inspected all bedrooms and found them to be clean and in good repair. All rooms were observed with the required furniture including a bed, dresser, nightstand, chair, and adequate storage space for resident’s personal belongings. All beds were observed with the required linens including a mattress
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY CONNECTED MEMORY CARE BOUTIQUE
FACILITY NUMBER: 198602982
VISIT DATE: 10/30/2024
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cover, fitted sheets, blanket, comforter, and pillow. Beds and bedding supplies were observed in good repair. All bedrooms were observed with adequate lighting. The department observed an adequate supply of linens stored in a hall closet.
Bathrooms The department observed the bathrooms to be within Tittle 22 regulations and fully operable. The showers had secured safety handrails, nonskid mats, and shower chairs. The water temperature measured 116.8- degrees and 116.7-degrees Fahrenheit. The department observed an adequate supply of bath towel and wash clothes stored in a hall closest in good repair. The department observed storage space for resident’s hygiene products. An additional supply was observed stored in the garage and are inaccessible to residents.
Kitchen The kitchen was inspected and observed to be clean and sanitary. The department observed all appliances to be operational and in good repair. The department observed an ample supply of dishware, cookware, and cutleries in good repair. The department observed knives and sharps secured in a locked cabinet in the kitchen and are inaccessible to residents. All cleaning supplies were observed secured in a locked cabinet under the kitchen sink and are inaccessible to residents. The department observed a 3-day supply of perishable and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 115.5-degrees Fahrenheit.
Common Rooms The department toured all rooms in the home. The department observed the facility to be furnished appropriately to accommodate all residents. The living room had chairs to accommodate all residents. The dining room has a large circular table to accommodate all residents. The department observed games, activities, puzzles and reading material available for residents. The facility was
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY CONNECTED MEMORY CARE BOUTIQUE
FACILITY NUMBER: 198602982
VISIT DATE: 10/30/2024
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maintained at a comfortable temperature. All rooms were observed with ample lighting. All walkways were observed to be clean, clear, and free of obstructions and hazards.
Safety The department observed all required signs posted throughout the facility. The department observed two (2) fully charged fire extinguishers last serviced on 11/20/23, 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 10/13/24. The department observed the facility has a working landline.
File Review The department reviewed three (3) staff files and observed they had the required documentation, training, and certification. The Administrator Certificate is valid till 11/21/24. The department did look and see that the renewal is pending, and observed the documents submitted. The department reviewed the files for five (5) residents and found they contained the required documents and current assessments. The facility has liability insurance through Accord that is valid till 02/19/2025. During facility file review, the department observed licensing fees are current.
Medications The department observed all Centrally Stored Medication secured in a locked cabinet in the office area. All medications were observed in their original packaging. The department reviewed the medications and medication administration record (MAR) for five (5) residents and found they were consistent with properly documented records.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY CONNECTED MEMORY CARE BOUTIQUE
FACILITY NUMBER: 198602982
VISIT DATE: 10/30/2024
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Infection Control During the visit, the department observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. The department observed required infection control signs posted throughout the facility. The department observed a 90-day supply of PPEs stored in the garage.

The department did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Kristi Simomian, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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