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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802527
Report Date: 12/16/2021
Date Signed: 12/17/2021 06:54:26 AM

Document Has Been Signed on 12/17/2021 06:54 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SCANDIA GUEST LODGEFACILITY NUMBER:
197802527
ADMINISTRATOR:ERICKA JIMENEZFACILITY TYPE:
735
ADDRESS:1248 E. 10TH STREETTELEPHONE:
(562) 599-2451
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY: 74CENSUS: 56DATE:
12/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Ericka JimenezTIME COMPLETED:
04:00 PM
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On 12/16/21 at 1:23p.m., Licensing Program Analyst (LPA) Susan Campos, conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator, Ericka Jimenez , and explained the purpose of today’s visit. This facility is licensed to serve (74) Mentally Disabled: (72) Ambulatory and (2) Non-Ambulatory Adults aged 18-59. There are currently (24) clients in care over the age of 59. The last fire/emergency disaster drill was conducted on 11/15/21. The last fire inspection was conducted on 3/13/21. This facility is located in a residential neighborhood with two buildings, two stories, a gate surrounding the perimeter of the building and security cameras installed in the common areas only. The facility grounds include: Administrative office (two rooms/bathroom and a Medication room, Kitchen, (3) Dining rooms, Pantry, (2) Laundry rooms, Storage rooms (located on the first floor), Maintenance room, and (15) Apartments with 2 or 3 rooms in each apartment (private and semi-private): Upstairs; Apartment #4, #5,#6,#7,#8,#12,#13,#14,#15,#16. Downstairs; Apartment #2,#3,#9,#10,#11 with one bathroom in each apartment. Outdoor grounds were toured and observed to have smoking and non-designated smoking areas, with shaded picnic benches, tables and chairs adjacent to the activity room, accessible to the clients. The grounds were free of debris, and exits and pathways were free of obstructions. There were no firearms or bodies of water in the premises. LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. The LPA and Ms. Jimenez inspected the following rooms: Apt.9-Room2, Apt.2-Room16, Apt.8-Room2, Apt.16-Room2, and Apt.2Room2. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. 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. The LPA inspected and tested the water temperature and observed hot water temperature to be 118.1 degrees Fahrenheit. A comfortable temperature of 75 degrees Fahrenheit was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
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 2
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: SCANDIA GUEST LODGE
FACILITY NUMBER: 197802527
VISIT DATE: 12/16/2021
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clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. LPA observed (12) Fire extinguishers charged, and facility smoke detectors were checked and also (2) carbon monoxide stand alone were working and operable. A review of Medication Administration Records (MAR) was maintained in order and accurate. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations in common areas and restrooms. LPA observed staff and clients were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to administrator Ericka Jimenez.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC809 (FAS) - (06/04)
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