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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600071
Report Date: 05/20/2024
Date Signed: 05/20/2024 02:11:09 PM

Document Has Been Signed on 05/20/2024 02:11 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:LONG BEACH GROUP HOMEFACILITY NUMBER:
191600071
ADMINISTRATOR/
DIRECTOR:
VINCENT NGUYENFACILITY TYPE:
735
ADDRESS:8330 HENDRIE STREETTELEPHONE:
(562) 708-3850
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 3DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:41 PM
MET WITH:Administrator Victor IniguezTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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On 05/20/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Victor Iniguez as the purpose of the visit was explained. The facility is licensed to serve (6) ambulatory clients ages 18-59 with developmental disabilities. Current facility census is 3, clients are linked to the Harbor Regional center. Facility fees are current.

The facility is a single-story structure located in a residential neighborhood and consists of the following; (4) client bedrooms, (1) staff bathroom (1) client bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with 2 tables with attached seating. No weapons not bodies of water are on the premises. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients. Exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 3 client records, 3 P&I ledgers and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last emergency drill was conducted on 4/25/24, 2 fire extinguisher fully charged, carbon monoxide and smoke detectors are operational.

Exit interview conducted with Administrator Victor Iniguez, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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