<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602620
Report Date: 10/15/2021
Date Signed: 10/17/2021 11:31:46 PM

Document Has Been Signed on 10/17/2021 11:31 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:LONG BEACH RESIDENTIALFACILITY NUMBER:
198602620
ADMINISTRATOR:BONZON, TEDFACILITY TYPE:
735
ADDRESS:4201 EAST 10TH STREETTELEPHONE:
(562) 433-2455
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY: 49CENSUS: 48DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Crystal Barrientos 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 10/15/21 Licensing Program Analysts (LPAS) Jade Jordan and Ngozi Nwaokoro made an unannounced visit to conduct an Annual Inspection, with an emphasis on infection control. LPA'S were met by facility Administrator Crystal Barrientos, and the Purpose of the visit was explained.

Upon Entry LPAS observed all staff to be wearing masks, and visitor screening system in pace. LPA's
were screened, answered questions in regards to Covid-19, a 30 day of supply of Full PPE'S were observed.
Visitors are requested to show proof of vaccination, and are screened.

The Facility has two buildings which is called East Wing and West Wing Building. The East Wing Building has two floors. The first floor which includes a staff front and back office, staff bathroom, main lobby, 2 storage rooms, 7 bedrooms, 1 shower room, 1 full bathroom, 1 half bathroom and a laundry room. On the second floor which includes a commercial kitchen, small dining room, big dining room, supplies room, 4 bedrooms and two full bathrooms. The West Wing building, there has two floors, first floor which includes 8 bedrooms, 2 full bathroom, 1 half bathroom, 2 maintenance rooms and a storage room. The second floor which includes 8 bedrooms, 2 full bathroom, 1 half bathroom and a storage room. There is also a large patio/smoking area, pantry room, storage room, community room which includes the doctor office and an administrator office in the facility. The client bedrooms are spacious and will easily accommodate the client's furnishings. The passageways, walkways, driveways, steps and patios are free from obstructions.

LPAS observed the Commercial kitchen to have rust, and dry wall was coming apart. The stove burners
and oven were not functional, and a leaking dishwasher. LPA's Advised due to the disrepair and condition of the kitchen, citations will be issued.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
VISIT DATE: 10/15/2021
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
26
27
28
29
30
31
32
LPAS toured client rooms 7,9,10 14,15, 16,19,24,18. During the physical tour LPAs observed room number 10's bathroom shower/bath to have black water coming from drain, about an inch deep.. LPAs advised that citations will be issued for disrepair

Technical Advisories Were given for the following areas:
Cosmetic areas within the facility such as paint in the bathrooms, hall ways, baseboards.
Mirrors in bathroom that need to be replaced due to discoloring, Missing face plates in rooms on electrical outlets.

An exit interview was conducted, and citations were issued for areas listed above.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/17/2021 11:31 PM - It Cannot Be Edited


Created By: Jade Jordan On 10/15/2021 at 02:18 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: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
80088 (e)(3) Furniture, Fixtures, Equipment, and Supplies.
(e) Faucets used by clients for personal care such as shaving and grooming shall...
(3) All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.


POC Due Date: 10/18/2021
Plan of Correction
1
2
3
4
This was not met as evidenced by: Based on LPA observation LPAs observed Bathtub clogged with black water an inch deep.This poses a potential personal rights, health and safety risk to clients in care. Administrator will contact maintenance and fix by poc due date. A picture of bathroom will be sent to LPA
Section Cited
Deficient Practice Statement
1
2
3
4
80087 Buildings and Grounds(a)
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This was not met as evidenced by: LPAS observation of kitchen dry wall cracking and falling apart, dishwasher leaking water, rusted pipes/baseboards, stove burner and oven not working, Appliance in disrepair

POC Due Date: 11/04/2021
Plan of Correction
1
2
3
4
Administrator will send a picture of corrections kitchen by 11/04/21
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:Michael Cava
LICENSING EVALUATOR NAME:Jade Jordan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3