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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608273
Report Date: 05/13/2021
Date Signed: 05/26/2021 03:47:55 PM

Document Has Been Signed on 05/26/2021 03:47 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ROSE GARDEN VILLA AT BIXBYFACILITY NUMBER:
197608273
ADMINISTRATOR:JUN FAUSTO FIGUEROAFACILITY TYPE:
740
ADDRESS:3754 PACIFIC AVENUETELEPHONE:
(562) 424-9469
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: DATE:
05/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:TIME COMPLETED:
02:45 PM
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Licensing Program Manager (LPM) Janae Hammond and Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by licensee Rose Matute and the purpose of today’s visit was explained. The facility is licensed to serve 6 elderly 59 and older.

There are currently 6 elder residents in care. All 5 non-ambulatory and 1 ambulatory clients. The facility is a 1-story structure with 5 bedrooms and 2 bathrooms, living room, kitchen and patio.


LPA Calderon and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were accessible to clients. Smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 05/26/2021 03:47 PM - It Cannot Be Edited


Created By: Jose Calderon On 05/13/2021 at 02:25 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: ROSE GARDEN VILLA AT BIXBY
FACILITY NUMBER: 197608273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
88705(F)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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87705 Care of Persons with Dementia :(f) The following shall be stored inaccessible to residents with dementia:: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.. This requirement is not met by based on obersavation licensee did not lock washer area which contained chenicals, this poses a immediate exposure to residents in care.


POC Due Date: 05/14/2021
Plan of Correction
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Spoke to licensee that all toxic items are locked up to residents. Licensee shall provided plan of action to LPA by 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:Janae Hammond
LICENSING EVALUATOR NAME:Jose Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2021


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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ROSE GARDEN VILLA AT BIXBY
FACILITY NUMBER: 197608273
VISIT DATE: 05/13/2021
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LPA advised the Administrator 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.

During today’s visit there was deficiencies under California code of regulation title 22, division 6, chapter 8.

Exit interview held and appeal rights provided. A copy of the report was provided to licensee Rose Matute.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ROSE GARDEN VILLA AT BIXBY
FACILITY NUMBER: 197608273
VISIT DATE: 05/13/2021
NARRATIVE
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LPA advised the Administrator 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.

During today’s visit there where was deficiencies observed under California code of regulation title 22, division 6, chapter 8.

Exit interview held. A copy of the report was provided to Rose Matute

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/26/2021 03:47 PM - It Cannot Be Edited


Created By: Jose Calderon On 05/14/2021 at 09:28 AM
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: ROSE GARDEN VILLA AT BIXBY
FACILITY NUMBER: 197608273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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2
3
4
87705(F)(2)
87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


POC Due Date: 05/14/2021
Plan of Correction
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Spoke to licensee that all toxic items are to be locked up to residents. Licensee shall provide plan of action to LPA by due date

Received POC from licensee
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:Janae Hammond
LICENSING EVALUATOR NAME:Jose Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021


LIC809 (FAS) - (06/04)
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