197800307-10-31-2023-11-AS-JCAN-CWXNVS-20231025104826

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197800307
Report Date: 10/25/2023
Date Signed: 10/31/2023 09:38:29 AM

Document Has Been Signed on 10/31/2023 09:38 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	HAYES HOME		FACILITY NUMBER:	197800307
ADMINISTRATOR:	GUZMAN,THERESA		FACILITY TYPE:	735
ADDRESS:	2470 HAYES AVE.		TELEPHONE:	(562) 424-4930
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90810
CAPACITY: 6		CENSUS: 3	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	ADMINISTRATOR THERESA GUZMAN		TIME COMPLETED:	11:15 AM

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 10/25/2023 at 09:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Hayes Home Facility. LPA Calderon was allowed entry into the facility by Administrator Theresa Guzman. The facility is licensed for six residents aged 18 to 59 and over of which (3) ambulatory residents. Currently, there are (3) residents residing in the facility, between the age of 18 to 59. LPA Calderon explained to Administrator Theresa Guzman, the purpose of the one-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: three (3) resident service records, three (3) resident medication records, two (2) staff records. LPA Calderon interviewed three (3) residents and two (2) staff members for visit and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 07/01/2023. The one-story residential home consists of four (4) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day (2) supply perishable and seven-day (7) supply of non-perishable foods are present in the facility. Emergency Water supply is found in the garage.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAYES HOME	FACILITY NUMBER: 197800307
	VISIT DATE: 10/25/2023

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 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 closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 110 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 111 degrees Fahrenheit. Kitchen hot water temperature properly measured at 109 degrees Fahrenheit. Facility (2) carbon Monoxide and (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility two (2) 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 first aid kit is fully stocked with manual 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. Three (3) resident files were reviewed and found to be complete. LPA Calderon reviewed three (3) resident medications and they were all found to be administered according to doctor's orders. Two (2) staff file were checked and have the required documents. LPA Calderon noted the Administrator Theresa Guzman Certification # 6010468735 expiration date of 02/05/2024 was valid at time of visit. The facility does handle resident's money/cash resources and Western Surety Company #66159149 for $2000.00 expiration date 03/01/2024 is valid. General Lability Policy #ACP GLO 3039643790 policy period from 04/17/2023 to 04/17/2024 underwritten by Nationwide Mutual Insurance Company Inc, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Theresa Guzman who will email copy insurance contact to LPA Calderon on 12/01/2023. All the required documents are posted in the facility in a clearly visible area. LPA Calderon reviewed LIC500 and noted all staff associated to facility.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAYES HOME	FACILITY NUMBER: 197800307
	VISIT DATE: 10/25/2023

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 were NOT wearing face coverings. LPA Calderon noted required postings throughout the facility. LPA Calderon observed the facility has a thirty-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Theresa Guzman 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.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any 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 Administrator Theresa Guzman.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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