198320107-11-30-2023-11-AS-EGOZ-CY3UZ7-20231130150105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320107
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:01:15 PM

Document Has Been Signed on 11/30/2023 03:01 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	OAKTREE MANOR		FACILITY NUMBER:	198320107
ADMINISTRATOR:	DADABHOY, MUQEET		FACILITY TYPE:	740
ADDRESS:	3269 SAN ANSELINE AVE		TELEPHONE:	(310) 251-2382
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 5	DATE:	11/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Alvin Ramos		TIME COMPLETED:	03:15 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 11/30/23, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with house manager Alvin Ramos and explained the purpose of today’s visit. LPA was granted entry to this facility. The facility is licensed to operate for (6) ambulatory and may be (6) bedridden elderly residents ages 60 and above. The facility is approved for (6) hospice residents. During this inspection, LPA observed construction being done in this facility. The construction is blocking emergency exit for bedroom #3. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, two (2) common bathrooms, (1) staff bedroom which is under construction, a living area, a dining area, a kitchen, and an outside patio area which is not accessible to residents due to construction. LPA toured the physical plant with house manager Alvin Ramos. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. The bathrooms were found to be within Title 22 regulation. Water temperature properly measured between 105F-120F. A comfortable temperature was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers are fully charged, and smoke detectors operable. A working landline telephone remains available. A review of Medication Administration Records and Fire Drill are maintained and in order. The last fire drill was conducted on 09/03/23. Evaluation Report continues LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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

Document Has Been Signed on 11/30/2023 03:01 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKTREE MANOR	FACILITY NUMBER: 198320107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [1] out of [5] residents. Resident Luningning Espina is missing a TB test and results, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Licensee shall provide TB test with results for resident: Luningning Espina to LPA Elvira Gonzalez via fax to (424) 544-1016 or email to Elvira.Gonzalez@dss.ca.gov

Type B

Section Cited

HSC

87305(a)(b)

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not notifying the department prior to construction starting which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/14/2023
	Plan of Correction
1 2 3 4	Licensee is to submit a letter advising the departmenNotes:///8825833F00615185/33104F27CDF10937882582B20052BA04/B41CA5DF85EE714A88258A7700783190 LIC809-Dt of the nature of the construction being done. The licensee shall also submit a plan of action on how they will handle residents throught the construction process and a plan of action in case of an emergency. Licensee is to submit copies of floor plan with modifications being made and accurante permits from Fire Department. This is to be submitted by fax or email to LPA.

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: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKTREE MANOR	FACILITY NUMBER: 198320107
	VISIT DATE: 11/30/2023

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 observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and 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. The facility has an approved Mitigation Plan Report on file with CCLD.

Deficiencies:
During this inspection LPA observed construction being done in facitlity. Licensee did not notify the department of these plans. While reviewing resident files, LPA observed that resident #4 was missing a TB test along with results.

Deficiencies are issued and an exit interview was conducted with house manager Alvin Ramos. A copy of this report is provided along with the appeal rights.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3