198320391-7-26-2024-11-AS-EDAT-D7JUPP-20240726154552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320391
Report Date: 07/26/2024
Date Signed: 07/26/2024 03:46:35 PM

Document Has Been Signed on 07/26/2024 03:46 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:	COAST TO COAST SENIOR WELLNESS		FACILITY NUMBER:	198320391
ADMINISTRATOR:	BAUGUESS, LESLIE		FACILITY TYPE:	740
ADDRESS:	5561 E VERNON STREET		TELEPHONE:	(562) 204-6245
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 6	DATE:	07/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Lesle Bauguess & Darwin Padolina		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 07/26/24, Licensing Program Analysts (LPAs) Ernand Dabuet and Hollie Enriquez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with administrator and owner Leslie Bauguess and Darwin Padolina explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents of which (5)) may be non-ambulatory. The facility is approved for (4) hospice residents. Currently, the facility has (1) resident in hospice care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, one (1) staff bedroom, (1) staff bathroom, a living area, a dining area, a kitchen, and an outside covered patio area. LPAs toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.9 degree F. A comfortable temperature of 73 degree F. was maintained in the facility. LPAs observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. A landline telephone was in working condition. Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COAST TO COAST SENIOR WELLNESS	FACILITY NUMBER: 198320391
	VISIT DATE: 07/26/2024

NARRATIVE

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During the visit, LPAs observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPAs observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPAs observed First Aid Kit was maintained. The facility has current liability insurance on file effective 03/01/24 - 03/01/25. The facility is current on Community Care Licensing annual dues.

An audit of residents #1-#5 (R1-R5) service files and staff #1-#5 (S1-S5) personnel files revealed to be complete. The facility has a current Administrators Certificate for Leslie Bauguess #6052747740 Exp. 05/17/25.

Deficiencies:
During audit of personnel records staff #2, did not have Health Screening LIC 503 on file along with TB test results.

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 Leslie Bauguess 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: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2024 03:46 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COAST TO COAST SENIOR WELLNESS	FACILITY NUMBER: 198320391
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(b)(2)

87412 Personnel Records (b) Personnel records shall be maintained for all volunteers and shall contain the following: (2) Health screening documents as specified in Section 87411(f). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section. LPAs identified staff #2 did not have LIC 503 Health Screening or TB test results as indicated on LIC 503. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	Licensee will ensure that all personnel staff maintain in file an LIC 503 Health Screening with TB Test results completed for staff #2. Licensee will provide correction by POC due date: 08/09/24 to ernand.dabuet@dss.ca.gov

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: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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