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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320253
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:17:01 PM

Document Has Been Signed on 10/30/2024 05:17 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:BEVERLY HOMES - LAWNDALEFACILITY NUMBER:
198320253
ADMINISTRATOR/
DIRECTOR:		CHIONG, BEVERLYFACILITY TYPE:
735
ADDRESS:4558 WEST 163RD STTELEPHONE:
(626) 389-7498
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 4CENSUS: 4DATE:
10/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:53 PM
MET WITH:Celerina MatibagTIME VISIT/
INSPECTION COMPLETED:
05:17 PM
NARRATIVE
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On 10/30/24, Licensing Program Analyst (LPA) Felisa Shirley visited this facility to investigate a complaint. During the course of investigation learned that resident S-1 has not been TB tested which is a safety risk to clients in care.


The following documents were requested and received during the visit:

· Physicians Report
· Admission agreement
· IPP

Deficiencies were cited for this visit.

An exit interview was conducted with staff, Celerina Matibag and a hard copy of the report was provided to be given to Administrator, Jesus “Jun” Chiong.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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Document Has Been Signed on 10/30/2024 05:17 PM - It Cannot Be Edited


Created By: Felisa Shirley On 10/30/2024 at 04:55 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BEVERLY HOMES - LAWNDALE
FACILITY NUMBER: 198320253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
80069(c)(1)

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80069 Client Medical Assessment

c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This
requirement is not met as evidenced by:
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Administrator shall meet with client’s parents, and service coordinator to come up with a plan to get client TB tested or request an exception for this client. Please submit plan of correction to LPA Felisa Shirley's Attn by fax 424-544-1016 or email to felisa.shirley@dss.ca.gov by POC due date of 12/2/24.
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Based on record review, LPA learned that C-1 have refused to submit to TB test or chest x-ray. This is a potential health and safety risk to clients in care.
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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
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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