198320283-8-5-2023-11-AS-EDAT-CUF5VB-20230805201716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320283
Report Date: 08/05/2023
Date Signed: 08/05/2023 08:17:34 PM

Document Has Been Signed on 08/05/2023 08:17 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	VERNON COTTAGE		FACILITY NUMBER:	198320283
ADMINISTRATOR:	UMANA, JOSE		FACILITY TYPE:	740
ADDRESS:	2312 ROSWELL AVE		TELEPHONE:	(562) 342-6145
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 6	DATE:	08/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Jose Umana		TIME COMPLETED:	03:59 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 08/05/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Jose Umana. The facility is licensed to operate for (6) non-ambulatory of which (1) may be bedridden elderly adults ages 60 and above. The facility is approved for (4) hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (4) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 107.2 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguisher were fully charged. A review of the Medication Records Administration (MAR) was observed to be maintained in order and complete. (Evaluation Report continues LIC 809-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023

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: VERNON COTTAGE	FACILITY NUMBER: 198320283
	VISIT DATE: 08/05/2023

NARRATIVE

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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 the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last emergency disaster drill was conducted on 08/01/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 02/01/23 through 02/01/24.

An audit of residents #1-#6 (R1-R6) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. Interviews were conducted with (6) residents and (2) staff. The facility has the current administrator's certification on file for Elsa Roman #6040880740 Exp. 06/23/24.

Deficiencies:

LPA observed a cracked window in bathroom #2 and #3.
LPA observed a window screen in bedroom #2 need replacement
LPA observed activity room sliding door screen need replacement

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Jose Umana and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/05/2023 08:17 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: VERNON COTTAGE	FACILITY NUMBER: 198320283
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(c)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above. LPA identified (4) items needing repairs. A bedroom window screen, sliding door screen, (2) bathroom windows with cracks. The violation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2023
	Plan of Correction
1 2 3 4	Licensee will adhere to Title 22 Sec 87303 and will ensure to have the facility in good repairs at all times. Window screen, sliding door screen and small bathroom windows in bathroom #2 & #3 will need to be replaced. Proof of correction must be sent to LPA by POC 09/05/23.

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023

LIC809 (FAS) - (06/04)

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