197803185-7-24-2023-11-AS-JCAN-CTYTL5-20230722144858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803185
Report Date: 07/22/2023
Date Signed: 07/24/2023 10:05:04 AM

Document Has Been Signed on 07/24/2023 10:05 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	COUNTRY CLUB VILLA		FACILITY NUMBER:	197803185
ADMINISTRATOR:	MAX IGLESIAS		FACILITY TYPE:	740
ADDRESS:	269 EAST SAN ANTONIO DRIVE		TELEPHONE:	(562) 595-9886
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	6	CENSUS: 5	DATE:	07/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:52 AM
MET WITH:	ADMINISTRATOR MAX IGELIAS		TIME COMPLETED:	03:00 PM

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 07/22/2023 at 12:00 PM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Country Club Villa Facility. LPA Calderon was allowed entry into the facility by Administrator Max Iglesias. Administrator Max Iglesias was asked questions regarding the full care tools control package (13) sections. Administrator Max Iglesias took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for six (6) adult clients with developmental disabilities. Currently, there are five (5) residents residing in the facility with developmental disabilities. LPA Calderon explained to Administrator Max Iglesias, the purpose of the one year (1) 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: five (5) resident service records, five (5) resident medication records, four (4) staff records. LPA Calderon interviewed five (5) residents and four (4) staff members for visit. LPA Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 06/02/2023. The one story residential home consists of five (5) resident bedrooms, four (4) 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-way (2) supply perishable and seven day (7) supply of non-perishable foods are present in the facility. Emergency Water seven day (7) supply is found in the garage.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023

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 3

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: COUNTRY CLUB VILLA	FACILITY NUMBER: 197803185
	VISIT DATE: 07/22/2023

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
26
27
28
29
30
31
32

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 and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit. Bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 109 degrees Fahrenheit. Bathroom #4 hot water temperature properly measured at 107 degrees Fahrenheit. Kitchen hot water temperature properly measured at 111 degrees Fahrenheit. Facility (2) carbon Monoxide and (8) Smoke Detectors hard wired and 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 (1) 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. LPA Calderon noted the Administrator Max Iglesias Certification # 6012339740 expiration date of 11/22/2023 was valid at time of visit. The facility does NOT handle resident's money/cash resources and NO Surety bond is needed. Commercial General Liability Policy #HFS0008452 policy period from 06/30/2023 to 06/30/2024 and a Commercial Professional Liability Insurance Policy #HFS0008452 policy period from 06/30/2023 to 06/30/2024 underwritten by Scottsdale Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Max Iglesias who will email full copy of insurance contact which shows all coverages to LPA Calderon on 07/31/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: COUNTRY CLUB VILLA	FACILITY NUMBER: 197803185
	VISIT DATE: 07/22/2023

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
26
27
28
29
30
31
32

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 and residents were NOT wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Max Iglesias 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 Max Iglesias.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3