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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600071
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:14:00 PM

Document Has Been Signed on 03/19/2025 03:14 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) 594-8327
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 4DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Victor Iniguez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 03/19/2025 at 9:10am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Victor Iniguez, Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for ambulatory only, prefers to serve developmentally disable adults ages 18 thru 59 years. Currently, the home has (4) clients. The clients are Harbor Regional Center clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facility has a annual fee of $454 due on 05/31/2025, LPA provided pin #493119 with the option for the facility to make an online payment. The liability insurance is with Zurich American Insurance Company (NAIC #16535) and (policy # 2024-07644) effective 09/15/2024 - 09/15/2025 with each occurrence at $1,000,000 and general aggregate $3,000,000.

The facility is a single story home located in a residential neighborhood. The property consists of the following: 4 client bedrooms, 2 bathrooms (in located inside client room), staff office, living room, kitchen, dining room, attached garage with an additional refrigerator, a pantry storage with can perishable items which aslo houses the washer and dryer and an outdoor shaded area.

Between the hours of 9:28am -11:00am LPA conducted a records review of (4) client records, (4) staff records, (4) clients Personal & Incidental Records, (3) Client Medication Administration Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit and did not observed any discrepancies at the time of visit.

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LONG BEACH GROUP HOME
FACILITY NUMBER: 191600071
VISIT DATE: 03/19/2025
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Between the hours of 11:23am - 11:45am LPA and Victor Iniguez toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F
( Bathroom #1: 113.9 F, Bathroom #2 113.7F, & Kitchen 113.0F).

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with Victor Iniguez, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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