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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600097
Report Date: 12/13/2023
Date Signed: 12/13/2023 03:07:31 PM

Document Has Been Signed on 12/13/2023 03:07 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:ABILITYFIRST LONG BEACH CENTER ADULT DAY PROGRAMFACILITY NUMBER:
191600097
ADMINISTRATOR:SCHLOSSER, BARBARAFACILITY TYPE:
775
ADDRESS:3770 E WILLOW STTELEPHONE:
(562) 426-6161
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 40CENSUS: 36DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Jordan Quenun, SupervisorTIME COMPLETED:
03:26 PM
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On 12/13/23 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual inspection visit, using the full cares tool. LPA was met by Adult Day Program (ADP) Supervisor Jordan Quenun, and the purpose of the visit was explained.
Upon entry, LPA Leon observed Covid-19 signage outside the automatic front doors. LPA was requested to sign in, with contact information and purpose of visit.

The Facility Building is located on a Main Street (E Willow St.), with front and side pedestrian entrances. Facility has three motor vehicle entrances, two (2) located on E Willow St. and one (1) located on Grand Ave. The interior physical structure consisted of two (2), large, multi-use activity rooms, of which both rooms can be used for Adult Day Program clients. Facility also holds a license for an After-School Care Program (Ages 8-18+). ADP clients are predominately community based. There is one commercial sized teaching kitchen, green belt area for outdoor activities or gardening, indoor community based pool which is currently under renovation, locked and secure, laundry skills room, exercise room, and an administrative wing. A total of 6 bathrooms between the two activity areas, all meeting title 22 regulations with hand soap, paper towels and appropriate covered trash can. One of these restrooms is the designated isolation/sick room, stocked with an appropriate resting cot. The pool, and the administrative wing, also include their own separate bathrooms, all meeting title 22 regulations. Water temperature was properly measured at an average of 107 degrees F. Bathrooms were clean and free of mold/mildew. Walkways were clear and free of obstruction and debris.
Hard wired smoke detectors, and separate smoke alarms were observed throughout the facility, fully operational. They are directly connected to the fire department, and was last serviced/inspected on 10/17/23. The last Fire drill was conducted on 09/20/23 and Earthquake drill on 10/19/23.
There are 5 service vehicles, all in good working condition and currently up to date with tags. Engine service is done through Pep-Boys. Wheelchair lifts on the community vans are serviced by Sunset Vans, located in Downey. All Wheelchair lift maintenance are done on-site, at the above-mentioned ADP.
Report continues, see LIC809C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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: ABILITYFIRST LONG BEACH CENTER ADULT DAY PROGRAM
FACILITY NUMBER: 191600097
VISIT DATE: 12/13/2023
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LPA reviewed 2 client records, and 2 staff records. One (1) client file needed an updated health screening (LIC602), see LIC809D.

The facility is following their mitigation plan. LPA observed a supply of PPE's which included: Face Shields, Surgical Masks, N95's, Gloves, Disinfectant, Paper towels, Soap, gowns, and Hand Sanitizer. The facility has an emergency plan in place, and has designated staff that will work with a client should they fall ill while under their care.
N95 fit testing has been provided to staff, and the facility continues to offer Covid-19 testing to all staff, as requested, as Long Beach Dept. of Public Health is on the same block. Program supervisor informs LPA of all changes through telephone conference.

One (1) deficiency was cited during this visit, see LIC809D. An exit interview was conducted with Program Supervisor, Jordan Quenun. A copy of the appeal rights and this report was provided to Program Supervisor, Jordan Quenun.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2023 03:07 PM - It Cannot Be Edited


Created By: Mario Leon On 12/13/2023 at 02:19 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: ABILITYFIRST LONG BEACH CENTER ADULT DAY PROGRAM
FACILITY NUMBER: 191600097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above in one (1) client's folder by having a Physician's Report for Community Care Facilities (LIC601), out of date (undated), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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LPA and Program Supervisor (PS) have agreed to contact the client's responsible person(s) (RP) to obtain an updated, written, medical assessment for the subject's folder. PS has emailed RP on 12/13/23 at 1:51PM and will obtain the LIC602 within the next 30 days. PS will send LIC602 via email to LPA at mario.leon@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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


LIC809 (FAS) - (06/04)
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