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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608273
Report Date: 05/24/2024
Date Signed: 05/24/2024 02:54:51 PM


Document Has Been Signed on 05/24/2024 02:54 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:ROSE GARDEN VILLA AT BIXBYFACILITY NUMBER:
197608273
ADMINISTRATOR:JUN FAUSTO FIGUEROAFACILITY TYPE:
740
ADDRESS:3754 PACIFIC AVENUETELEPHONE:
(562) 612-3528
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 6DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Jun Fausto Figueroa/AdministratorTIME COMPLETED:
02:54 PM
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On 5/24/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Jun Figueroa /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above, of which (6) can be non-ambulatory. The facility has an approved hospice waiver for (4).

The facility is a one-story residential home consists of (6) resident bedrooms, (2) resident bathrooms, living rooms, dining room, kitchen, staff room, office area, storage area, attached garage washer and dryer room, backyard with table and chairs.



LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (6) bedrooms and (2) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 115.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
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: ROSE GARDEN VILLA AT BIXBY
FACILITY NUMBER: 197608273
VISIT DATE: 05/24/2024
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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 5/24/24.

A review of (4) residents' service files and (4) staff personnel files was maintained in order. LPA reviewed (4) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Not recent LIC 602A for (R#2 and R#4).

-Unlocked supplies found on kitchen sink and bathroom.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Jun Figueroa / Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/24/2024 02:54 PM - It Cannot Be Edited

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: ROSE GARDEN VILLA AT BIXBY
FACILITY NUMBER: 197608273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation, the licensee did not comply with the section cited above in having unlocked cleaning supplies in bathroom and kitchen cabinet under the sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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 Administrator locked cleaning supplies while LPA was in the facility.Licensee will ensure that all cleaning supplies are locked at all times. As part of Plan of Correction, licensee will re-train facility staff on how to keep cleaning supplies locked at all times. A proof of staff training will be email to LPA before POC due date.
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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/24/2024 02:54 PM - It Cannot Be Edited

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: ROSE GARDEN VILLA AT BIXBY
FACILITY NUMBER: 197608273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a current LIC 602A for R#2 and R#4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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Licensee will ensure residents with dementia will have an annual assesment at all time. As plan of correction-POC the licensee will provide updated LIC 602 forms for R#2 and R#4 to LPA via email before POC due date.
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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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