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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603005
Report Date: 12/01/2022
Date Signed: 12/14/2022 01:44:23 PM

Document Has Been Signed on 12/14/2022 01:44 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CHERRY BLOSSOMS ELDERCAREFACILITY NUMBER:
198603005
ADMINISTRATOR:GARCIA, RONEILIOFACILITY TYPE:
740
ADDRESS:1416 FERN AVETELEPHONE:
(424) 757-2323
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 6DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LISA BUENCILLOTIME COMPLETED:
12:00 PM
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On 12/1/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. LPA Montoya called Administrator Roneilio Garcia and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA met with House Manager Lisa Buencillo and Angela Tortona and they toured the inside and outside grounds of the facility.

The facility is licensed for six (6) non- ambulatory, of which six (6) may be bedridden; approved hospice waiver for six (6) residents. LPA observed six (6) residents of which three (3) are hospice and two (2) direct caregivers during the visit.


The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, three (3) bathrooms, one (1) living area, one (1) dining area, kitchen, covered outside patio and an attached two (2) car garage.

During the tour, LPA did not observe bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 117.9 degrees Fahrenheit. A comfortable temperature was maintained in the facility. Smoke detectors and carbon monoxide are operational.



LPA observed the facility was found to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility conducted a Fire/Safety Drill on 9/24/2022. A working telephone remains available.

Evaluation Report Continues on LIC 809C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CHERRY BLOSSOMS ELDERCARE
FACILITY NUMBER: 198603005
VISIT DATE: 12/01/2022
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

Technical Assistance and citations were issued.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to House Manager Lisa Buencillo.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/14/2022 01:44 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 12/01/2022 at 02:08 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
MONTEREY PARK, CA 91754

FACILITY NAME: CHERRY BLOSSOMS ELDERCARE
FACILITY NUMBER: 198603005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA Montoya observed the medical assessments and appraisals of residents (R1, R3, R4 & R5) with dementia were not done annually. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2022
Plan of Correction
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Administrator shall review the section cited above and shall submit a self-certification of knowledge and understanding. Administrator shall submit current medical assessments and reappraisals of residents with dementia by the POC due date, 12/19/2022 to CCLD via email to lourdes.montoya@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/14/2022 01:44 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 12/01/2022 at 02:16 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
MONTEREY PARK, CA 91754

FACILITY NAME: CHERRY BLOSSOMS ELDERCARE
FACILITY NUMBER: 198603005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
FIRE SAFETY - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA Montoya observed both fire extinguishers in the dining area and garage were not serviced annually. They were both last serviced on 2/24/2021. The fire extinguisher in the garage is not mounted on the wall. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2022
Plan of Correction
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Administrator shall ensure the fire extinguishers are serviced annually and mounted on the wall. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 12/19/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022


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