198320199-8-4-2022-11-AS-PSCT-CGYQ2G-20220804114706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320199
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:47:15 AM

Document Has Been Signed on 08/04/2022 11:47 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	KEEN HOME LONG BEACH		FACILITY NUMBER:	198320199
ADMINISTRATOR:	DUTILE, VIRGINIA (GINNY)		FACILITY TYPE:	740
ADDRESS:	6441 BIXBY HILL RD		TELEPHONE:	(562) 438-5336
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90803
CAPACITY:	6	CENSUS: 2	DATE:	08/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Adrian Herbas/Latoya Johnson		TIME COMPLETED:	11:45 AM

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On 8/04/2022, Licensing Program Analyst (LPA) Perry Scott and LPM Janae Hammond conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival, LPA called the facility to conduct a risk assessment. LPA spoke with administrator Adrien Herbas, who confirmed the facility is Covid-19 free. LPA/LPM met with administrator Adrien Herbas/Latoya Johnson shortly after and explained the purpose of today's visit.

Upon arrival at the facility, LPA/LPM met with administratior Adrien Herbas, who granted access and allowed LPA/LPM to enter the facility to conduct an annual inspection. Administrator Latoya Johnson joined the visit shortly after. The facility is licensed for six (6) bedridden residents and has an approved hospice waiver for (6); and there are two (2) residents present during today’s visit. Annual Fees are current during today’s visit.

During the visit, LPA/LPM toured the facility with Adrien and Latoya. This facility consists of six (6) resident bedrooms, three (2) full bathrooms and 1/2, kitchen, living room/TV room, receiving room, dining area, shaded patio, and a garage. Operable smoke detectors/carbon monoxide in bedrooms and hallways were observed. Two fire extinguishers last serviced on 04/17/2021 are in the kitchen and hallway. The last facility fire drill was on 06/24/22. LPA/LPM observed the facility is appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available.

Report Continued in LIC 809-C

There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. Potentially dangerous items are kept inaccessible to residents with dementia. Centrally stored medications are locked in a medication cart in the pantry. The first aid kit has all the required supplies.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: KEEN HOME LONG BEACH	FACILITY NUMBER: 198320199
	VISIT DATE: 08/04/2022

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Toxic chemicals are locked in a cabinet in the kitchen. The facility has a written emergency disaster plan. The facility is maintained at a comfortable temperature. LPA/LPM observed hot water temperature is measured at 105.5 degrees Fahrenheit. There are working lights or lamps in each room at the time of visit. There are grab bars for each toilet and shower used by residents. Showers have non-skid mats.

During the visit, LPA/LPM observed the following to be in compliance: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

Exit interview conducted. A copy of this report was provided to the Administrator Adrien Herbas and Latoya Johnson.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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