198601964-5-31-2024-11-AS-MLEN-D5SSCN-20240531134549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601964
Report Date: 05/31/2024
Date Signed: 05/31/2024 01:47:02 PM

Document Has Been Signed on 05/31/2024 01:47 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:	HAZELBROOK HOME		FACILITY NUMBER:	198601964
ADMINISTRATOR:	PEARL M LAMB		FACILITY TYPE:	735
ADDRESS:	4857 HAZELBROOK AVENUE		TELEPHONE:	(562) 452-7034
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	3	CENSUS: 3	DATE:	05/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:17 AM
MET WITH:	Maria Christina Serafico, Administrator		TIME COMPLETED:	02:18 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 05/31/24 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced, required, annual visit at the above-mentioned facility. LPA was met by Venus Scarbrough, DSP (S2), and later by Maria Christina Serafico, Administrator (S1), and the purpose of the visit was explained. The facility is licensed for three (3) non-ambulatory, developmentally disabled, clients. There are currently 3 clients residing in the facility, two (2) non-ambulatory and one (1) ambulatory client(s). As part of the inspection, LPA reviewed: 3 resident service records, 3 resident medication records, 2 staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 03/05/2024. The facility is located in a residential neighborhood and consists of the following: 3 resident bedrooms, 2 resident bathrooms, one (1) living room, 1 dining room, 1 kitchen and 1 office area, attached to the detached garage, backyard with shaded table and chairs. No weapons are stored on the premises. Kitchen was inspected and observed to be clean and operational. 1 medium-sized cockroach was observed, see LIC9102TV. A two-day supply of perishable and seven-day supply of non-perishable foods are present in the facility. LPA observed that all facility rooms are clean and in good repair. A comfortable temperature was observed at 71.2 degrees F, and the facility has central air and heating. LPA observed the following during inspection of resident’s rooms: All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA observed fully stocked closet with bedding, towels, and toiletries supplies. LPA observed one spider and cobwebs in the dining room corners, see LIC9102TA. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA observed bathrooms were found to be within Title 22 regulations. Kitchen hot water temperature properly measured at 109.9 degrees F. Facilities' five (5) Smoke Detectors also include Carbon Monoxide detection. All detectors are connected, were tested, and are working properly. The facilities' Fire Extinguisher was checked and found to be fully charged as of 05/14/24 accessible as needed. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Report continues, see LIC809C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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: HAZELBROOK HOME	FACILITY NUMBER: 198601964
	VISIT DATE: 05/31/2024

NARRATIVE

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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 home were free of debris and hazards and the outside patio is accessible to residents. 3 resident files were reviewed and found to be complete. LPA reviewed all resident medications and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documentation. LPA noted the Administrator Certification (S1) #7028306735, expiration date of 08/03/2024, was valid at time of visit. Facility manages clients P&I monies. LPA verified clients monthly balance and receipts which matching the clients Cash Resources information. All facilities' required documents are posted in the facility, in a clearly visible area.

There have been no deficiencies cited during today's visit, one technical violation note has been provided and one technical assistance note has been provided. See LIC9102TV and LIC9102TA.

LPA held an exit interview with Maria Cristina Serafico, Administrator, and a copy of this report and LIC9102TV and LIC9102TA has been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

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