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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320357
Report Date: 06/19/2023
Date Signed: 06/19/2023 12:40:37 PM

Document Has Been Signed on 06/19/2023 12:40 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:SERRA PROJECT LONG BEACHFACILITY NUMBER:
198320357
ADMINISTRATOR:MANCILLA, CHRISTINAFACILITY TYPE:
736
ADDRESS:638 SUNRISE BLVD.TELEPHONE:
(562) 595-4877
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 11CENSUS: 8DATE:
06/19/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Christina Mancilla-DirectorTIME COMPLETED:
12:40 PM
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On 6/19/2023 Licensing Program Analysts (LPA)/Alfonso Iniguez conducted a pre-licensing evaluation change of ownership (CHOW) for an RCFCI (Residential Care Facility for the Chronically Ill) facility type. Today’s pre-licensing evaluation was conducted with Director/Christina Mancilla.

The licensee has applied for a license to serve (11) 18 and over adults. The fire clearance is approved for (7) ambulatory, (4) non-ambulatory and (0) bedridden residents.

LPA and director toured facility Kitchen, Dining Room, Breakfast Room, Living Room, Sun Room, (11) Bedrooms, (4) Bathrooms, Garage/Back house, Back Yard, and Patio with shaded porch. LPA observed sufficient storage areas for kitchen supplies, linens, medications (secured) and chemicals (secured).

LPA observed the following during this visit:

MEDICATIONS

There is a locked centralized storage area for Resident medications.

PHYSICAL PLANT

LPA observed the facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 85°F. degrees. Open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Carbon monoxide/Smoke detectors operate properly.

CONTINUE ON LIC 809C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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: SERRA PROJECT LONG BEACH
FACILITY NUMBER: 198320357
VISIT DATE: 06/19/2023
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BEDROOMS

No client bedroom is a passageway to another room, bath, or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair.

There is dresser and closet space for each client that includes at least two (2) drawers of dresser space per client. There is a chair and lamp for each client and at least one (1) night stand per two (2) clients.

BATHROOMS

There is at least (6) toilets and washbasins per six (6) clients, family, and personnel. There is at least one (1) shower per ten (10) clients, family, and personnel. Hot water temperature is between 105°F.-120°F. degrees Fahrenheit. Bathrooms are located near client bedrooms

SUPPLIES

There are client personal hygiene supplies to include soap, toothpaste, toilet paper and feminine products. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE

Dining room is near kitchen. Refrigerator and freezer are clean and have the capacity to store at least two (2) days of perishable foods. There is storage for seven (7) day supply of non-perishable food. There are enough tableware, tables, dishes, and utensils. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

CONTINUE ON LIC809C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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: SERRA PROJECT LONG BEACH
FACILITY NUMBER: 198320357
VISIT DATE: 06/19/2023
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RECORDS

LPA conducted a records review of (4) client records, (4) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

ADMINISTRATION

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES

There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies to include board games located in the living room.

MISCELLANEOUS

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

During this pre-licensing inspection, LPA did not find corrections are needed.

LPA conducted the Component III Orientation with the Licensee and copy of this report was provided.

A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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