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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601701
Report Date: 08/30/2023
Date Signed: 09/01/2023 08:35:17 AM


Document Has Been Signed on 09/01/2023 08:35 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:CITADEL HOMES, INC.FACILITY NUMBER:
198601701
ADMINISTRATOR:MARISSA G. MASHBURNFACILITY TYPE:
740
ADDRESS:1840 W. AQUARIUS STREETTELEPHONE:
(562) 426-8091
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY:6CENSUS: 4DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:MANAGER LESTER ABESAMESTIME COMPLETED:
03:30 PM
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On 08/30/2023 at 1:00 PM Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Citadel Home Facility. LPA Calderon was allowed entry into the facility by Manager Lester Abesames. Manager Lester Abesames asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for six (6) adult clients aged 60 and over. Currently, there are four (4) residents residing in the facility 60 years or older and two (2) hospice residents.

LPA Calderon explained to Manager Lester Abesames, the purpose of the one-year (1) 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) resident service records, four (4) resident medication records, three (3) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 06/03/2023. The one-story residential home consists of four (5) resident bedrooms, three (3) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and 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 seven-day (7) supply is found in the garage.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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: CITADEL HOMES, INC.
FACILITY NUMBER: 198601701
VISIT DATE: 08/30/2023
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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 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 111 degrees Fahrenheit, and bathroom #3 hot water temperature properly measured at 108 degrees Fahrenheit. Kitchen hot water temperature properly measured at 120 degrees Fahrenheit. Facility (2) carbon Monoxide and (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. 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 (3) 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 home were free of debris and hazards. Outside patio accessible to residents. LPA Calderon noted the Administrator Marissa G Mashburn Certification # 6022227740 expiration date of 11/11/2024 was valid at time of visit. The facility does handle resident's money/cash resources and a Surety bond with Western Surety Company #65711290 for $2000.00 was noted by LPA Calderon. Commercial General Liability Policy #001453840 policy period from 06/30/2023 to 06/30/2024 underwritten by James River Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Marissa Mashburn who will email full insurance contact to LPA Calderon on 09/15/2023. All the required documents are posted in the facility in a clearly visible area to all clients and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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: CITADEL HOMES, INC.
FACILITY NUMBER: 198601701
VISIT DATE: 08/30/2023
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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, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Manager Lester Abesames 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 any 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 Manager Lester Abesames.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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