198204036-1-22-2024-11-AS-MLEN-CZR39C-20240122170256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204036
Report Date: 01/22/2024
Date Signed: 01/22/2024 05:03:04 PM

Document Has Been Signed on 01/22/2024 05:03 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:	EUGENIA'S HOUSE		FACILITY NUMBER:	198204036
ADMINISTRATOR:	ERLINDA HATMAL		FACILITY TYPE:	740
ADDRESS:	4321 N. COUNTRY CLUB LANE		TELEPHONE:	5622900122
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	6	CENSUS: 6	DATE:	01/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Ophelia Aplicador, Licensee		TIME COMPLETED:	05:02 PM

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On 01/22/2023 at 08:30 AM, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual inspection visit at the Eugenia’s House Adult Residential Facility. LPA Leon was allowed entry into the facility by Licensee, Ophelia Aplicador (S1). The facility is licensed for six (6) adult clients 59 year or older. Currently, there are six (6) residents residing in the facility 59 years or older.

LPA explained the purpose of the one-year (1) Annual Inspection visit, and LPA and S1 took a tour of the inside and outside of the facility grounds. LPA reviewed: six (6) resident records, six (6) resident medication records, two (2) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 12/20/2023. The one-story residential home consists of four (4) resident bedrooms, three (3) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and LPA observed the stove top to be in disrepair, see LIC809D. A two-day (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.

LPA 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 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 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 observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 117.1 degrees F, #2 hot water temperature properly measured at 117.7 degrees F and #3 hot water temperature properly measured at 118.6 degrees Fahrenheit.

Report Continues, see LIC809C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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: EUGENIA'S HOUSE	FACILITY NUMBER: 198204036
	VISIT DATE: 01/22/2024

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Kitchen hot water temperature properly measured at 115 degrees F. Facilities' nine (9) Smoke Detectors were tested, two (2) of which also contain carbon Monoxide detection, are inter-connected and all are working properly. The facility (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 in the kitchen, inaccessible to residents. Facility's two (2) first aid kits are fully stocked, one (1) 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 is accessible to residents. Six (6) resident files were reviewed and were found to be complete. LPA reviewed six (6) resident medications and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. Licensee was not able to provide updated liability insurance.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Licensee, Ophelia Aplicador (S1).

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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