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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204036
Report Date: 02/25/2022
Date Signed: 02/25/2022 11:52:13 AM

Document Has Been Signed on 02/25/2022 11:52 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EUGENIA'S HOUSEFACILITY NUMBER:
198204036
ADMINISTRATOR:MARIA OFELIA APLICADORFACILITY TYPE:
740
ADDRESS:4321 N. COUNTRY CLUB LANETELEPHONE:
(562) 290-0122
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 5DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Maria Ofelia Aplicador, Administrator TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Maria Ofelia Aplicador, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve elderly residents age 60 and above. Fire cleared for 5 non-ambulatory & 1 bedridden. Mentally alert residents only.

There are currently 5 residents in placement. The facility is a single-story structure located in a residential neighborhood. It consists of the following: Outdoor patio/deck, a living room, dining area, kitchen, laundry area, 4 bedrooms, 3 bathrooms, and a 2 car garage.

LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 117.3 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed for screening protocols for visitors, staff and residents, sanitizing stations located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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Document Has Been Signed on 02/25/2022 11:52 AM - It Cannot Be Edited


Created By: Ulysses Coronel On 02/25/2022 at 11:25 AM
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: EUGENIA'S HOUSE
FACILITY NUMBER: 198204036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above the kitchen drawer and linen closet door were in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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The administrator agreed to have said drawer and closet door repaired and create a plan to ensure that the facility is kept in good repair at all times. Proof of correction will be submitted via email at ulysses.coronel@dss.ca.gov.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited abovethe window screen in bedroom#3 had tears and was installed during time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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The administrator agreed to have said window screen repaired and create a plan to ensure that all window screens are maintained in good repair. Proof of correction will be submitted via email at ulysses.coronel@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
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: EUGENIA'S HOUSE
FACILITY NUMBER: 198204036
VISIT DATE: 02/25/2022
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

The following deficiencies observed during todays visit; the window screen in bedroom#3 had tears and was installed during time of visit, the kitchen drawer and linen closet door were in disrepair. Title 22, Division 5 Chapter 8 are being cited on attached LIC809D.

Plan of corrections were developed and an exit interview was held. A copy of the report and appeals rights were provided to Maria Ofelia Aplicador, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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