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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602620
Report Date: 01/27/2024
Date Signed: 01/27/2024 04:13:19 PM

Document Has Been Signed on 01/27/2024 04:13 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:LONG BEACH RESIDENTIALFACILITY NUMBER:
198602620
ADMINISTRATOR:CRYSTAL BARRIENTOSFACILITY TYPE:
735
ADDRESS:4201 EAST 10TH STREETTELEPHONE:
(562) 433-2455
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY: 49CENSUS: 49DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Administrator Marinel "Amanda" LunaTIME COMPLETED:
04:30 PM
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On 01/27/2024 at 8:13 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Staff Geraldine Phillips. Administrator Marinel "Amanda" Luna joined us 30 minutes later. LPA explained the purpose of the visit and were accompanied by Staff inside and outside the facility during this inspection.

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 are 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 facility is approved to serve 49 ambulatory clients age range 18 – 59 years old. The facility currently has six clients over 59 years old.

Outside grounds were toured. Patio furniture under a shaded area was accessible to clients. There are no security bars or weapons on the premises.

Continued to LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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 13
Document Has Been Signed on 01/27/2024 04:13 PM - It Cannot Be Edited


Created By: Regina Cloyd On 01/27/2024 at 03:21 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: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential safety and personal rights risk to persons in care. Some of the hallway tiles on the first floor are damanged and upstairs shower leaks into1L and 2L's bathroom in the East Wing. One door in the entryway is off the hinges and a hole was observed in the door of room 13L in West Wing. New light bulbs are need in room 1L, 14L, and 19L. Room 13 had no lighting at all.
POC Due Date: 02/09/2024
Plan of Correction
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The maintenance man immediately added lights in rooms 14L and 19L. The Administrator will resolve other deficiencies before the POC due date and send photos of the repairs. The Administrator will also develop a preventative maintenance plan and email regina.cloyd@dss.ca.gov.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses a potential safety risk to persons in care. LPA observed an old bed spring outdoor and old refrigerator parts near the food storage area. LPA observed a bed spring on the second floor blocking the exit stairway in the back building.
POC Due Date: 02/09/2024
Plan of Correction
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 The Administrator will resolve deficiencies before the POC due date and send photos. The Administrator will also develop a preventative maintenance plan for building and grounds and email regina.cloyd@dss.ca.gov.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


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: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
VISIT DATE: 01/27/2024
NARRATIVE
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8 out of 8 client’s bedrooms were checked. Adequate dresser and closet space observed. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Toiletries are available to clients upon request. LPA Cloyd tested hot water temperature and it measured between 107 – 119 degrees Fahrenheit. This facility provides clients with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.



LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 01/09/2024. First aid kit is fully stocked with manual.

Three (3) out of five (5) staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Two staff members were interviewed.

Seven (7) client records were reviewed and, 7 out of 7 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. Three clients were interviewed. Three client medications were reviewed.

Deficiencies are being cited based on LPA observation, in accordance with the California Code of Regulations, Title 22, see LIC809D.

Continue to LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
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: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
VISIT DATE: 01/27/2024
NARRATIVE
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During the facility tour, LPA did not observe the facility to be in good repair at all times for the safety and well-being of clients, employees, and visitors. Some of the hallway tiles on the first floor in the East Wing are damaged, one door in the entryway of the West Wing is off the hinges, a hole was observed in the door of room 13L, upstairs shower in the East Wing leaks into the dedicated bathroom for room 1L and 2L, and new light bulbs are need in room 1L, 14L, and 19L. Room 13 had no lighting at all. Findings were discussed with Administrator and Assistant as we toured the facility.

During the facility tour, LPA did not observe all outdoor and indoor passageway and stairways free of obstruction. LPA observed an old bed spring outdoor and old refrigerator parts near the food storage area. LPA observed a bed spring on the second floor blocking the exit stairway in the West wing.

An exit interview was conducted, technical assistance provided, plans of corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator Marinel "Amanda" Luna.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC809 (FAS) - (06/04)
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