198320262-6-17-2023-11-AS-JCAN-CSVRVE-20230617132125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320262
Report Date: 06/17/2023
Date Signed: 06/17/2023 02:41:20 PM

Document Has Been Signed on 06/17/2023 02:41 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	FLORESMA GUEST HOME		FACILITY NUMBER:	198320262
ADMINISTRATOR:	SERRANO, CARL		FACILITY TYPE:	740
ADDRESS:	1812 E. HARDWICK AVE		TELEPHONE:	(562) 895-2418
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	6	CENSUS: 3	DATE:	06/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	STAFF DOLORIS DELROSARIO		TIME COMPLETED:	02:00 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 06/17/2023 at 09:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Floresma Guest Home Facility. LPA Calderon was allowed entry into the facility by Staff Dolores Delrosario. Administrator Mary Jean B Catacutan was asked questions regarding the full care tools control package (13) sections. Staff Delrosario took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for six (6) adult clients with developmental disabilities. Currently, there are three (3) residents residing in the facility with developmental disabilities. LPA Calderon explained to Staff Dolores Delrosrio, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: three (3) resident service records, three (3) resident medication records, five (5) staff records. LPA Calderon interviewed three (3) residents and five (5) staff members for visit. LPA Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 04/08/2023. The one-story residential home consists of five (5) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day (2) supply perishable and seven-day (7) supply of non-perishable foods are NOT present in the facility. Emergency Water seven-day (7) supply is found in the garage.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

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: FLORESMA GUEST HOME	FACILITY NUMBER: 198320262
	VISIT DATE: 06/17/2023

NARRATIVE

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LPA Calderon 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 Calderon 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 Calderon 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 Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 111 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Kitchen hot water temperature properly measured at 117 degrees Fahrenheit. Facility two (2) carbon Monoxide and seven (7) Smoke Detectors hard wired and were tested and are working properly. The facility three (3) 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. Facility first aid kit one (1) is fully stocked 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 accessible to residents. LPA Calderon reviewed three (3) resident files and found to be complete. LPA Calderon reviewed three (3) resident medications and they were all found to be administered according to doctor's orders. five (5) staff files were checked and do NOT have the required documents. LPA Calderon noted the Administrator Mary Jean B Catacutan Certification # 6036186740 expiration date of 08/02/2023 was valid at time of visit. The facility does NOT handle resident's money/cash resources and NO Surety bond is needed. Commercial General Liability Policy #0100238020 policy period from 04/29/2023 to 04/29/2024 and a Commercial Professional Liability Insurance Policy #0100238020 policy period from 04/29/2023 to 04/29/2024 underwritten by Kinsale Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Mary Jean B Catacutan who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 06/30/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted staff Dolores Delrosario not associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

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: FLORESMA GUEST HOME	FACILITY NUMBER: 198320262
	VISIT DATE: 06/17/2023

NARRATIVE

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During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Mary Jean B Catacutan to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did observe deficiency therefore citation 87355 (c)(1) was issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Mary Jean B Catacutan.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/17/2023 02:41 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FLORESMA GUEST HOME	FACILITY NUMBER: 198320262
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(C)(1)

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care. 87355Criminal Record Clearance(a)The Department shall conduct a criminal record review...
	POC Due Date: 06/19/2023
	Plan of Correction
1 2 3 4	Licensee to associated staff Doloris Delrosario to facility going foward

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

LIC809 (FAS) - (06/04)

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