South Bay Memory Care

Type of visit: Required - 1 Year

On 11/8/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Rosselyn Fagaragan/Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (5) residents ages 60 and above of which (6) non-ambulatory only. Facility has an approved hospice waiver for (2) patients. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining area, kitchen, three (3) bedrooms, two (2) bathrooms, laundry area in the garage, indoor/outdoor activity area, shaded patio area, and attached two (2) car garage. LPA Iniguez toured the physical plant with director. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1, #2, and #3 and smoke and carbon monoxide combo are all in operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 114.9°F, Bathroom #1:113.1°F, Bathroom #2:112.4°F. Evaluation Report Continues LIC 809-C LPA Iniguez observed the facility clean, sanitary and appropriately furnished at the time of the 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 available maintained properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files and (3) Medication Administration Records (MAR) were maintained in order. First AID kit was checked. Last fire disaster drill was on: 10/8/2023. LPA observed the facility's infection control practices. A copy of the liability insurance was provided to LPA during visit. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Rosselyn Fagaragan/Director.the state’s words, verbatim · CDSS document, Nov 8, 2023

Type of visit: Required - 1 Year

On 11/302022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA called to conduct a risk assessment and spoke with Vatche Khedesian who confirmed the facility is free of Covid-19 infection. LPA met with House Manager Victoria Martinez and explained the purpose of today’s visit. The facility is licensed for six (6) non-ambulatory residents, with a Dementia Care Program and an approved hospice waiver for two (2) residents. Currently, there is one (1) Hospice resident present during today’s visit. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining area, kitchen, three (3) bedrooms, two (2) bathrooms, laundry area in the garage, indoor/outdoor activity area, shaded patio area, and attached two (2) car garage. LPA Montoya toured the facility with House Manager Martinez. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client 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. The water temperature measured at 119.6 degrees Fahrenheit. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are three (3) fire extinguishers fully charged, one in the kitchen, and two in the hallways to resident bedrooms, smoke detectors and carbon monoxide were operable. Evaluation Report Continues on LIC 809C 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 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. LPA Montoya requested a copy of the facility's liability insurance emailed to lourdes.montoya@dss.ca.gov. Technical Advisory was 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. LPA observed and took photos of three large blue trash bins and five large gray trash bins stored along the right side yard pathway from the front yard to the backyard of the facility. The facility sketch shows this pathway must be always clear. LPA also observed Staff #1 is not associated to the facility. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to House Manager Victoria Martinez.the state’s words, verbatim · CDSS document, Nov 30, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year Annual visit. The primary focus is on the Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Bunker called the facility and spoke to Licensee Lauren Mahakian via telephone to conduct a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Director of Care Mary Lou Giebelb and explained the purpose of today's visit. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility garage entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional over 90-day supply of PPE is stored in the storage closet; sufficient paper, cleaning, and disinfecting supplies were observed. LPA reviewed the facility’s surveillance testing records. LPA verified that the facility has an approved Mitigation Plan Report. Mrs. Giebelb stated staff and residents are fully vaccinated. All staff has completed the N95 fit testing requirement. The facility is licensed for six (6) non-ambulatory residents, with a Dementia Care Program and an approved hospice waiver for two (2) residents. Currently, there is one (1) Hospice resident present during today’s visit. See continued LIC809-C on page #2 Continued LIC809-C page #2 Mrs. Giebel and LPA Bunker toured the entire facility inside and outside grounds. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining area, kitchen, three (3) bedrooms, three (3) bathrooms, laundry area in the garage, indoor/outdoor activity area, patio shaded area, attached two (2) car garage, front and back yard landscape is in good condition at the time of visit. Documents were posted as mandated. During the tour, LPA Bunker observed the facility’s infection control practices. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The resident's bedrooms were inspected for, safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. First aid kit is fully stocked with manual, hot water temperature 119.3 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, records medications is centrally stored and properly locked in the kitchen, with current record, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on 07/09/2021. No firearms on the premises, resident's bedroom windows have no sliding window locks with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards. Director of Care Mary Lou Giebel states staff was given training on dependent adult and elder abuse reporting. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 4, 2021