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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803288
Report Date: 06/25/2022
Date Signed: 06/25/2022 03:56:05 PM

Document Has Been Signed on 06/25/2022 03:56 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:RIDGEWOOD HOMEFACILITY NUMBER:
197803288
ADMINISTRATOR:EILEEN CORREOS-VAZQUEZFACILITY TYPE:
735
ADDRESS:1072 EAST RIDGEWOOD STREETTELEPHONE:
(562) 627-9612
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 4CENSUS: 4DATE:
06/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Maria Cruz - House ManagerTIME COMPLETED:
03:47 PM
NARRATIVE
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On 06/25/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with the house manager Maria Cruz. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) adults ages 18 through 59 years of age. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, two (2) common bathrooms, a living area, dining area, kitchen, staff bedroom, and outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105..0 degrees F. A comfortable temperature of 74 degrees 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 objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were charged and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The last fire drill was on 05/27/22. The facility has a working landline telephone.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: RIDGEWOOD HOME
FACILITY NUMBER: 197803288
VISIT DATE: 06/25/2022
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DEFICIENCIES:
During the inspection visit at 1:10 pm, LPA observed (1) butcher knife on the kitchen counter, and (1) sharp scissors in an unlocked kitchen drawer. At 1:12 pm LPA observed a powder bleach under the kitchen sink in an unlocked cabinet. At 2:24 pm, LPA observed (2) non-operable smoke detectors (1) inside a client's room and the other in the hallway/office area.

INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident vaccination records, test results, and daily temperature screening. The facility has an approved CCLD Mitigation Plan.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 1.

Deficiencies are issued and an exit interview is conducted with Maria Cruz. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2022 03:56 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/25/2022 at 02:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: RIDGEWOOD HOME
FACILITY NUMBER: 197803288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above and found (2) non working smoke detectors in client's room and hallway/office. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 80087. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations The licensee will need to replace non-operable smoke detectors with operable dectors. Plan of correction will be submitted by POC due date: 06/27/22.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in (3) [(objects) sharp scissors, buther knife and toxic cleaning solution were not stored in lock cabinets. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 80087. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations The licensee will ensure all hazardous objects are stored in locked cabinets at all times. Plan of correction will be submitted by POC due date: 06/27/22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2022


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