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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800131
Report Date: 10/23/2022
Date Signed: 10/23/2022 01:44:46 PM


Document Has Been Signed on 10/23/2022 01:44 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:CHATEAU LONG BEACHFACILITY NUMBER:
197800131
ADMINISTRATOR:BEATRICE ROMEOFACILITY TYPE:
740
ADDRESS:3100 E. ARTESIA BLVD.TELEPHONE:
(562) 428-5371
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:184CENSUS: 93DATE:
10/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Khatera BahadoryTIME COMPLETED:
12:59 PM
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On 10/23/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Khatera Bahadory. LPA explained the purpose of today’s visit. The facility is licensed to serve (184) of which (178) non-ambulatory and (6) bedridden elderly adults ages 60 and above. The facility is approved for (6) hospice residents.

The facility is a two-story structure located in a commercial neighborhood. It consists of the following: Eighty (80) resident bedrooms with a bathroom in each unit, four (4) public bathrooms, a reception area, a beauty shop, an activity room, a kitchen, a dining, a laundry room, a medication room, three (3) outside patios, and offices.

LPA toured the physical plant with Bahadory. There were no bodies of water or obstructions 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. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #109; #114; #111: #236; #239 and call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature 105.0 degrees F. The room temperature ranged from 74 degrees F.

LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. Several working landline phones are available on-site. A review of (8) residents' service files (R1-R8) and (7) staff personnel files (S1-S7) and Medication Administration Records (MAR) were maintained in order. A review of staff CPR/First Aid Training are current. A current liability insurance effective 08/06/22 - 08/06/23 was on file.
(Evaluation Report continues on LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2022
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: CHATEAU LONG BEACH
FACILITY NUMBER: 197800131
VISIT DATE: 10/23/2022
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DEFICIENCY:
At 12pm, LPA identified hazardous paint chemicals stored in unlocked cabinets in the dining room and beauty salon area accessible to residents in care.

INFECTION CONTROL:
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 staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of residents' and staff COVID vaccinations was conducted for (R1-R8) and staff (S1-S7). The facility has provided CCLD with an approved Mitigation Plan and has submitted an Infection Control Plan 2022 to CCLD. A 2022 Monkey Pox Inspection Control was submitted to CCLD as well.

Deficiency is issued and an exit interview is conducted with Khatera Bahadory. A copy of this report is provided along with the appeal rights.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2022 01:44 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: CHATEAU LONG BEACH
FACILITY NUMBER: 197800131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2022

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 failed to adhere to section cited above. LPA identified paint toxic chemicals not stored in locked cabinets. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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The licensee will adhere to Title 22 section 87309 and ensure that all hazardous chemical solutions are stored and locked. This violation must be corrected by POC date 10/24/22.

*This violation was corrected during visit.*
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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2022
LIC809 (FAS) - (06/04)
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