191671691-8-2-2024-11-AS-PSCT-D7RSCV-20240802134609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191671691
Report Date: 08/02/2024
Date Signed: 08/02/2024 01:46:15 PM

Document Has Been Signed on 08/02/2024 01:46 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:	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: 117	DATE:	08/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Francisca Vallejo		TIME COMPLETED:	02:00 PM

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On 08/02/24, at 9:30am Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Amalia Esquivias, Administrator, and Francisca Vallejo, Assistant Administrator and explained the purpose of today’s visit. The facility is approved for (213) elderly adults ages 60 and over, ambulatory, and non-ambulatory. Currently, the facility has (117) residents. The facilities annual fees are current.

The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (132) residents' rooms, (132) resident bathrooms, (6) common bathrooms, dining room, commercial kitchen, staff area, office area, commercial washer and dryer room/ storage area, outdoor patio with umbrella, table, and chairs.

LPA conducted a records review of (7) resident records, (7) staff records, and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 regulations at the time of visit. All resident & staff records were complete. LPA reviewed (4) resident Medication Administration Records and did not observe any discrepancies at the time of visit.

LPA and the Assistant Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Five rooms per floor were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for residents’ personal belongings is available.

Report continued on LIC809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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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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: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 08/02/2024

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All rooms had the required furniture. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature in each bathroom per room inspected were found to be within Title 22 regulations. LPA observed the facility to have a first aid kits, manual, and emergency supplies. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary, well-maintained, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were stored and accessible to residents. The commercial kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. LPA observed the kitchen area to be clean and free from pests. The facilities fire extinguishers were checked and found to be fully charged and accessible; and last serviced on 09/20/2023. All exit doors in the facility have alarm systems. The facility has hardwired and battery-operated smoke and carbon monoxide detectors and are in working condition. A working landline telephone remains available. The last fire/emergency drill was conducted on 07/22/2024. The facility has current liability insurance.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA further observed the facility to have a 90-day supply of Personal Protective Equipment (PPE). Facility had the proper signage posted (Facility Disaster Plan, Facility License, Administrator Certificate, Residents Personal Rights, etc.).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Exit interview was held and a copy of the Facility Evaluation Report was provided to with Amalia Esquivias, Administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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