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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803185
Report Date: 07/20/2024
Date Signed: 07/20/2024 12:49:33 PM


Document Has Been Signed on 07/20/2024 12:49 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:COUNTRY CLUB VILLAFACILITY NUMBER:
197803185
ADMINISTRATOR:MAX IGLESIASFACILITY TYPE:
740
ADDRESS:269 EAST SAN ANTONIO DRIVETELEPHONE:
(562) 595-9886
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 5DATE:
07/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Max and Wilma IglesiasTIME COMPLETED:
01:05 PM
NARRATIVE
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On 07/20/24 at 9:26 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Assistant Administrator Wilma Iglesias. Administrator Max Iglesias joined us shortly afterwards.

The facility is licensed to serve six (6) elderly residents, all of which (6) may be non-ambulatory with a hospice waiver approved for two (2) aged 60+ years. The facility currently has one resident on hospice.



The facility is a 1-story structure with 5 bedrooms, 4 bathrooms, living room, kitchen and inside and outside patio.

The Assistant Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured at 109.5F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809-C.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2024
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: COUNTRY CLUB VILLA
FACILITY NUMBER: 197803185
VISIT DATE: 07/20/2024
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Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced March 20, 2024 was observed in the kitchen area. Administrator tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and required criminal record clearances or criminal record exemptions.

5 resident records were reviewed and, 5 out of 5 resident records had medical assessments. Two residents’ medication was reviewed.

No deficiencies are being cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Assistant Administrator Wilma Iglesias.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024
LIC809 (FAS) - (06/04)
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