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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601645
Report Date: 06/03/2023
Date Signed: 06/12/2023 01:07:52 PM


Document Has Been Signed on 06/12/2023 01:07 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:BIXBY KNOLLS TOWERFACILITY NUMBER:
191601645
ADMINISTRATOR:ROB GOERZENFACILITY TYPE:
740
ADDRESS:3747 ATLANTIC AVENUETELEPHONE:
(562) 426-6125
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:65CENSUS: 42DATE:
06/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Mary Lou EscobedoTIME COMPLETED:
03:29 PM
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On 06/03/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Assisted Living Director Mary Lou Escobedo. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (65) non-ambulatory elderly adults ages 60 and above. Floors 4th, 5th and 6th are assisted living. Currently, the facility has (42) residents and (7) in hospice care. The facility is approved for (10) hospice residents.

The facility is a six story structure located in a commercial neighborhood. It consists of the following: (53) resident bedrooms in the assisted living area. Each room has a bathroom in the unit, an activity room, a dining area, a kitchen, and outside patio area. The building includes 2nd and 3rd floors as designated for skilled nursing.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected:#405, #408, #413, #506, #512, #515, #610, #615 and #620. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.0 – 111.9 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F.

LPA observed the facility to be 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 sufficient perishable and non-perishable food was maintained adequately. The facility has conducted monthly Fire Drills. The last Fire Drill was on 05/19/23. (Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BIXBY KNOLLS TOWER
FACILITY NUMBER: 191601645
VISIT DATE: 06/03/2023
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Each room had carbon monoxide and smoke detectors that were all operable. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. The facility is current with annual license fees. The facility has completed first aid kits on each floor.

LPA conducted an audit of resident #1-#5 (R1-R5) service files, and staff #1-#5 (S1-S5) personnel files were in order and complete. LPA conducted (4) resident and (4) staff interviews.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during the visit.

An exit interview was conducted with Mary Lou Escobeo, and a copy of the report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2023
LIC809 (FAS) - (06/04)
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