198320357-9-8-2023-11-AS-JCAN-CVFTYY-20230907150931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320357
Report Date: 09/07/2023
Date Signed: 09/08/2023 09:14:31 AM

Document Has Been Signed on 09/08/2023 09:14 AM - 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 BEACH		FACILITY NUMBER:	198320357
ADMINISTRATOR:	MANCILLA, CHRISTINA		FACILITY TYPE:	736
ADDRESS:	638 SUNRISE BLVD.		TELEPHONE:	(562) 595-4877
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY: 11		CENSUS: 8	DATE:	09/07/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	ADMINISTRATOR CHRISTINA MANCILLA		TIME COMPLETED:	03:30 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 09/07/2023 at 11:30 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Facility Serra Project Long Beach. LPA Calderon was allowed entry into the facility by Administrator Christina Mancilla. Administrator Christina Mancilla asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for eleven (11) adult chronically ill residents. The fire clearance is approved for (7) ambulatory, (4) non-ambulatory and (0) bedridden residents. Currently, there are (8) residents residing in the facility with chronically ill issues. LPA Calderon explained to Administrator Christina Mancilla, the purpose of the one-year 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: Four (4) residents service records, four (4) resident medication records, four (4) staff records. The facilities’ last fire drill was conducted on 06/15/2023. The two-story residential home, with a two-story carriage house and three (3) car garage on the same premises. The front house consists of eleven (11) resident bedrooms, six (6) resident bathrooms, living room, dining room, kitchen, butler’s pantry, staff room, office area, with two (2) washer and two (2) 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 present in the facility. Emergency Water supply located in the storage room.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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: 09/07/2023

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 NO 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 109 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 107 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 109 degrees, and bathroom #4 hot water temperature properly measured at 108 degrees. Kitchen hot water temperature properly measured at 117 degrees Fahrenheit. Facility (3) Carbon Monoxide and (18) Smoke Detectors hard wired and connected were tested and are working properly. The facility (9) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility do not have alarm systems when opened. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit 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 facility were free of debris and hazards. Outside patio accessible to residents and staff. Four (4) resident files were reviewed and found to be complete. LPA Calderon reviewed four (4) resident medications and they were all found to be administered according to doctor's orders. Four (4) staff files were checked and have the required documents. The facility does NOT handle resident's money/cash resources and a Surety bond is not needed. Commercial General Liability Policy #2023-38694-NPO policy period from 01/01/2023 to 01/01/2024 underwritten by Nonprofits Insurance Alliance of California, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Christina Mancilla who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 09/20/2023. All the required documents are posted in the facility in a clearly visible area.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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: 09/07/2023

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, and LPA Calderon noted required postings throughout the facility. LPA Calderon observed the facility has a thirty-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Christina Mancilla 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 not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Christina Mancilla.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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