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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802527
Report Date: 12/21/2023
Date Signed: 12/22/2023 08:03:46 AM

Document Has Been Signed on 12/22/2023 08:03 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: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: 72DATE:
12/21/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:ADMINISTRATOR ERICKA JIMENEZTIME COMPLETED:
03:00 PM
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On 12/21/2023, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Calderon met with administrator Erika Jimenez. LPA explained the purpose of today’s visit. The facility is licensed to serve (74) mentally disordered ambulatory adults ages 18-59 years of age.

The facility is a two-story two building structure located in a residential neighborhood. It consists of the following: (16) apartments with (3) clients’ bedrooms in each unit. Each apartment has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, administrative offices, laundry, and outside patio area. As part of the inspection, LPA Calderon reviewed: Seven (7) client service records, seven (7) client medication records, four (4) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed seven (7) clients and four (4) staff members for visit.

LPA Calderon toured the physical plant with Administrator Jimenez. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in adequate condition, lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected apartments: #2; #3; #7; #8; #9, and #12. Call buttons and smoke/carbon monoxide were all tested and were in operable condition. The water temperature ranged from 107.1 – 119.9 degrees F. The room temperature ranged from 73 – 76 degrees F. LPA Calderon noted the Administrator Ericka Jimenez Certification # 6029788735 expiration date of 03/26/2024 was valid at time of visit. The facility does handle resident's money/cash resources. Surety bond #276107 for $2500.00 is valid at time of inspection. Commercial General Liability Policy #ACPGLO3130353598 policy period from 03/01/2023 to 03/01/2024 underwritten by Preferred Professional Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. All the required documents are posted in the facility in a clearly visible area.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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: SCANDIA GUEST LODGE
FACILITY NUMBER: 197802527
VISIT DATE: 12/21/2023
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LPA Calderon observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. 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. The facility conducted Fire/Emergency Drills on 11/12/2023. A review of staff CPR/First Aid certificates are current.

LPA Calderon advised the Administrator Ericka Jimenez 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 Ericka Jimenez.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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