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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602021
Report Date: 12/19/2023
Date Signed: 12/19/2023 03:01:20 PM

Document Has Been Signed on 12/19/2023 03:01 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:COLE VOCATIONAL SERVICES BIXBY KNOLLSFACILITY NUMBER:
198602021
ADMINISTRATOR:THOMAS, FELICIAFACILITY TYPE:
775
ADDRESS:4343 ATLANTIC AVETELEPHONE:
(562) 490-0263
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 30CENSUS: 21DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:April StephensTIME COMPLETED:
03:00 PM
NARRATIVE
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On 12/19/23 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator April Stephens, and the purpose of today’s visit was explained. LPA was granted access to the facility. The facility is licensed to serve 30 developmentally disabled adults ages 18 and over.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) bathrooms, a garden room, art room, style room, computer room, relaxation room, game room, exercise room, kitchen, laundry room, and staff and nurse offices.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected and are in good condition and well maintained. LPA observed sufficient lighting was provided to clients and staff. Storage for client’s personal belongings was observed. Walls and floors were in good repair. The bathrooms were found to be within Title 22 regulation and were clean and operational. Water temperature properly measured at 112.1 F in bathroom #1, 111.3 F in bathroom #2, 111.5 F in bathroom #3, and 110.3 in bathroom #4. LPA observed a comfortable temperature was maintained in the facility. Storage areas for personal hygiene, cleaning supplies, toxins and sharps were not accessible to clients.

LPA observed the facility to be clean and properly furnished at the time of the visit. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguishers were fully charged, smoke detectors and carbon monoxide were operable. A stocked first aid kit along with manual was available. Exits and walkways around the facility were free of debris and hazards.

Continued on LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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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Document Has Been Signed on 12/19/2023 03:01 PM - It Cannot Be Edited


Created By: Elvira Gonzalez On 12/19/2023 at 01:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COLE VOCATIONAL SERVICES BIXBY KNOLLS
FACILITY NUMBER: 198602021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 5 out of 5 persons, Staff #1 Jelielyn Garcia, Staff #2 Yanira Pacheco, Staff #3 Ernest Esparza, Staff #4 Raymond Valera, Staff #5 Soriya Tuoth were missing a health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Licensee will submit a Health Screening for staff #1-#5 to LPA Elvira Gonzalez via fax or email by POC due date.
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 6 persons. Client James Theodores file was missing a Medical Assesment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Licensee will submit a Medical Assesment for client James Theodore to LPA Elvira Gonzalez via fax or email by POC due date.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/19/2023 03:01 PM - It Cannot Be Edited


Created By: Elvira Gonzalez On 12/19/2023 at 01:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COLE VOCATIONAL SERVICES BIXBY KNOLLS
FACILITY NUMBER: 198602021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 of 5 persons. Client James Theodores file is missing TB test with results record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Licensee will submit record of TB test with results to LPA Elvira Gonzalez by fax or email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COLE VOCATIONAL SERVICES BIXBY KNOLLS
FACILITY NUMBER: 198602021
VISIT DATE: 12/19/2023
NARRATIVE
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 During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan. The facility’s last fire drill was on 11/22/23.


During this inspection deficiencies were observed and cited, see LIC 809-D

An exit interview was conducted, and a copy of the Report and Appeal Rights was provided to Administrator April Stephens.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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