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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320310
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:22:18 PM

Document Has Been Signed on 09/20/2024 03:22 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:LONE STAR LONG BEACH ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198320310
ADMINISTRATOR/
DIRECTOR:		STINSON, RAHMIDFACILITY TYPE:
735
ADDRESS:6165 LINDEN AVETELEPHONE:
(818) 470-9185
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 6CENSUS: 4DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Case manager Lakesha JonesTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 09/20/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Case manager Lakesha Jones as the purpose of the visit was explained. The facility is licensed to 6 ambulatory adults ages 18-59. Facility fees are current.

Facility is a single-story house in a residential neighborhood that consist of the following: (4) bedroom of which 1 of the bedrooms used as a lounging room, (2) bathroom,,a case manager office, living room/dinning room area, kitchen, laundry area, a detached garage/storage unit and a backyard shaded patio area. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.



LPA conducted a records review of 3 staff records, 4 client records, and 4 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Fire extinguishers fully charged, carbon monoxide and smoke detectors are interconnected and operational. A landline and internet service were observed.

Deficiencies were cited on 809D page.

Exit interview conducted with Case manager Lakesha Jones, appeal rights explained, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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 5
Document Has Been Signed on 09/20/2024 03:22 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 09/20/2024 at 01:50 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: LONE STAR LONG BEACH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(D)
85068.2 Needs and Services

If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:
The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following:
Mental and emotional functioning.


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as needs and services plans for clients 1-4 are not completed, there is no info documented nor signed by clients
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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3
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Licensee to complete all needs and services and obtain client signatures by POC due date and submit proof of completion to LPA by POC due date.
Type B
Section Cited
CCR
80070(b)(5)(7)
80070 Client records

Names, addresses, and telephone numbers of the authorized representative.

Name, address and telephone number of physician and dentist, and other medical and mental health providers, if any.


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as emergency I.D form is blank for clients 3 and 4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee will review client forms and provide/update all information required by POC due date, license to provide proof to LPA of completion.
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
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/20/2024 03:22 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 09/20/2024 at 02:34 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: LONE STAR LONG BEACH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(d)(1)
80069 client medical assessment

In addition to Section 80069(c), the medical assessment for clients in ARFs shall include the following:

A physical examination of the person, indicating the physician's primary diagnosis and secondary diagnosis, if any.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Physician reports for client 2-3 does not have a diagnosis nor physician signature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee to review and complete clients physician report in addition to ensuring the physician provides requires signature by POC due date. Licensee to submit proof to LPA.

Type B
Section Cited
CCR
80069(c)(1)
80069 Client Medical Assessment © (1)
The medical assessment shall include the following:

The results of an examination for communicable tuberculosis and other contagious/infectious diseases.


Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA did not observe a TB test observed for client 3 in client file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee will ensure a TB test is performed and will send proof and results to LPA by POC due date.
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
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/20/2024 03:22 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 09/20/2024 at 02:39 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: LONE STAR LONG BEACH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(h)(4)
80075 Health Related Services

There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available:
It is recommended that the licensee obtain consent forms to permit the authorization of medical care.



Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as No consent forms observed in file for clients 3-4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee to review client files and ensure all required documents are signed and placed into the client file by POC due date, Licensee shall provide proof of completion to LPA.
Type B
Section Cited
CCR
80020(c)
80020 Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).



Deficient Practice Statement
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Based on (interview) and (record review)], the licensee did not comply with the section cited above as there have been no drill conducted at the facility at all which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee to conduct drill and document the drill type, and have all staff and clients that participated sign the document. Licensee to ensure all drills are conducted quartely and keep record of drills. Licensee to provide proof of completion by POC due date
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
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/20/2024 03:22 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 09/20/2024 at 02:54 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: LONE STAR LONG BEACH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
80075 Health Related Services
Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.


Deficient Practice Statement
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3
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Based on (interview) and (record review)], the licensee did not comply with the section cited above as the first aid/ CPR certificates for staff 2 and 3 are expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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3
4
Licensee shall enroll staff 2 and 3 in first aid/CPR course and provide LPA with proof of completion by POCdue date.
Type B
Section Cited
CCR
85064(k)
85064 Adminstrator Qualifications and Duties
Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.


Deficient Practice Statement
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Based on(interview) and (record review)], the licensee did not comply with the section cited above as required training was not observed in administrators (staff 3) file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Administrator to complete required training and submit proof to LPA by POC due date
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
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
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