191671691-7-7-2023-11-AS-JCAN-CTGU4Z-20230706151558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191671691
Report Date: 07/06/2023
Date Signed: 07/07/2023 08:19:15 AM

Document Has Been Signed on 07/07/2023 08:19 AM - 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:	CROFTON MANOR INN		FACILITY NUMBER:	191671691
ADMINISTRATOR:	AMALIA ESQUIVIAS		FACILITY TYPE:	740
ADDRESS:	1950 E. 5TH ST.		TELEPHONE:	(562) 437-0093
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	213	CENSUS: 118	DATE:	07/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	ASSISTANT ADMINISTRATOR CLAUDIA ESQUIVIAS		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/06/2023 at 09:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at Crofton Manor Inn Facility. LPA Calderon was allowed entry into the facility by Assistant Administrator Francisca Vallejo. The facility is licensed for 213 residents aged 59 and over. Currently, there are 118 residents residing in the facility of which 12 residents are in the memory care unit. LPA Calderon explained to Assistant Administrator Francisca Vallejo, the purpose of the 1-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Ten (10) resident service records, Ten (10) resident medication records. LPA Calderon interviewed six (6) residents and six (6) staff members for visit. LPA Calderon inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 06/02/2023. The two-story commercial building consisting of (132) resident bedrooms, (132) resident bathrooms, Six (6) common bathrooms, dining room, commercial kitchen, staff area, office area, commercial washer and dryer room/ storage area, backyard with umbrella with table and chairs. No weapons are stored in the premises. Commercial Kitchen was inspected and observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility kitchen. Seven (7) day emergency water supply is in the kitchen and storage room areas.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 07/06/2023

NARRATIVE

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During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Assistant Administrator Francisca Valllejo to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon 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 Assistant Administrator Francisca Vallejo.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 07/06/2023

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s #105, #106, #113, #206, #207, #212 rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked storage room with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 106 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 108 degrees Fahrenheit. Commercial Kitchen hot water temperature properly measured at 118 degrees Fahrenheit. Facility (10) Carbon Monoxide and (107) Smoke Detectors hard wired and connected were tested and are working properly. The facility (20) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility (20) first aid kits are fully stocked with manuals was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Ten (10) resident files were reviewed and found to be complete. LPA Calderon reviewed Ten (10) resident medications and they were all found to be administered according to doctor's orders. Six (6) staff files were checked and have the required documents. The facility does handle resident's money/cash resources. Surety bond #40087462 for a total coverage of $30,000 dollars underwritten by Platte River Insurance Company is valid at time of inspection. All the required documents are posted in the facility in a clearly visible area. LPA Calderon noted the Administrator Amalia Esquivias Certification # 6012234735 expiration date of 10/25/2023 was valid at time of visit. Commercial General Liability Policy #HFF0218512311 policy period from 01/01/2023 to 01/01/2024 and a Commercial Professional Liability Insurance Policy #MKLV5PSM000424 policy period from 01/01/2023 to 01/01/2024 underwritten by Hudson Insurance Company, coverage 2,000,000/5,000,000 is valid at time of inspection. LPA Calderon spoke to Assistant Administrator Francisca Vallejo who will email full copy of insurance contact which shows all coverages to LPA Calderon on 07/14/2023. All the required documents are posted in the facility in a clearly visible area to all staff, residents, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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