197803754-9-18-2024-11-AS-ZBRN-D98U7Y-20240918152041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803754
Report Date: 09/18/2024
Date Signed: 09/18/2024 03:21:35 PM

Document Has Been Signed on 09/18/2024 03:21 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	DOUGLAS RESIDENTIAL CARE		FACILITY NUMBER:	197803754
ADMINISTRATOR:	GLENDA D. MARQUEZ		FACILITY TYPE:	740
ADDRESS:	5332 E GREENMEADOW ST.		TELEPHONE:	(562) 420-3731
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 6	DATE:	09/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Charese Reyes, Administrator		TIME COMPLETED:	01:45 PM

NARRATIVE

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On 09/18/2024 at 09:47am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. LPA met with Charesa Reyes , Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents an approved hospice waiver for 1 resident. Three (3) of the residents are diagnosed with dementia, three (3) hospice resident, and (1) home health (1). The facility does not handle any of the residents’ money. The home is a two story home consisting of: (3) shared resident bedrooms, (2) shared bathroom, with a upstairs one (1) bathroom, and one (1) staff bedroom, a living room, kitchen with dining area, laundry room, an outdoor shaded patio area and a detached garage with an additional refrigerator.

At 10:00am LPA Zina Brown toured the inside and outside of the facility. All client room were checked. Resident bedrooms had the required furniture had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. 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, water temperature measured at 118.3F (bathroom #1), 118.5 F(bathroom #2) and 114.4 F (kitchen). Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents, fire extinguisher was fully charged. Carbon monoxide and smoke detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Report continues on LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina Brown	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DOUGLAS RESIDENTIAL CARE	FACILITY NUMBER: 197803754
	VISIT DATE: 09/18/2024

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On 09/18/2024 LPA conducted residence record review of 6 six residence. 3 out 6 residence physican report states the residence are bedridden. Based on LPA observation during inspection and additional records review, residence are listed as non-ambulatory.

On 09/18/2024, the administrator informed the LPA that the facility does not have liability insurance.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies.

Due to time constraints, LPA was unable to complete the inspection, LPA will return at a later date.
Additional citations maybe issued.

An exit interview was conducted, and a copy of Report and Appeal Rights provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina Brown	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/18/2024 03:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DOUGLAS RESIDENTIAL CARE	FACILITY NUMBER: 197803754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview the administrator does not have liability insurance which which poses personal rights risk to persons and residence in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	The administration will submit proof of liability insurance by POC date via email at zina.brown@dss.ca.gov

Type B

Section Cited

CCR

87458(b)(5)

The medical assessment shall include, but not be limited to: The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition, mental condition or both. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, 3 out of 6 residents records review, indicated on the physicians record, the residences are bedridden. Based on LPA observation and other records reviewed, residences do not appear to be bedridden. This poses as a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	The administrator shall clarify residence ambulatory status to determine if the residence are bedridden or nonambulatory. The facility will submit proof of updated physician report by POC due date via email at zina.brown@dss.ca.gov

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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina Brown	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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