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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602620
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:55:54 PM

Document Has Been Signed on 09/27/2024 12:55 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:LONG BEACH RESIDENTIALFACILITY NUMBER:
198602620
ADMINISTRATOR/
DIRECTOR:		CRYSTAL BARRIENTOSFACILITY TYPE:
735
ADDRESS:4201 EAST 10TH STREETTELEPHONE:
(562) 433-2455
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY: 49CENSUS: 46DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Administrator Johnathan DipalingTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 09/27/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Johnathan Dipaling as the purpose of the visit was explained. The facility is licensed to serve 49 ambulatory only adults ages 18- 59. Facility fees are current.

The Facility has two buildings of which male (West wing) and female (East wing) units. The East Wing Building has two floors. The first floor which includes a main lobby 2 offices 1 which houses a medication cart, staff bathroom, 2 storage rooms, 7 bedrooms, 1 shower room, 1 full bathroom, 1 half bathroom,and a laundry room. On the second floor there is 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, storage room, community which serves as an activity/ TV room.

LPA conducted a records review of 5 staff records, 4 client records, and 4 medication administration records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 08/27/24, fire extinguishers are located in both units and are fully charged, carbon monoxide and smoke detectors are operational.

Deficiencies are cited on a 809D page.

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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 3
Document Has Been Signed on 09/27/2024 12:55 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 09/27/2024 at 11:46 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(g)(1)(A-H)
80075 Health Related Services
The supplies shall include at least the following:
A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency
Sterile first aid dressings.
Bandages or roller bandages.
Adhesive tape.
Scissors.
Tweezers.
Thermometers.
Antiseptic solution.
Deficient Practice Statement
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Based on [(observation) and (interview) , the licensee did not comply with the section cited above as the facility does not have a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, Antiseptic solution, nor Sterile first aid dressings which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee to purchase required firt aid supplies and provide proof of purchase to LPA by POC due date.
Type B
Section Cited
CCR
80022(a)
80022 Plan of operation
Each licensee shall have and maintain on file a current, written, definitive plan of operation.


Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facilty is using a MAR however the MAR is being used incorrectly as LPA observed the MAR to be missing documentation regarding medication refusals throughout the month of September 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee to conduct inservice will all staf that assist with medication passes and review the importance of medication procedurs including medication documentation. Licensee to provide proof of inserve to LPA by POC due date. Licnesee will also ensure to communicate with prescribing physician when persons in care are refusing medications regularly.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/27/2024 12:55 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 09/27/2024 at 12:22 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087Buildings 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.

Deficient Practice Statement
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Based on [(observation) on the mens wing of the facility LPA observed broken tiles in the upstairs bathroom, a bedroom door to be off its hinges, and pieces of broken glass on the steps of an entry way which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee to repair LPAs observations by POC due date and submit proof of repairs to LPA by POC due date
Type B
Section Cited
CCR
80087(c)
80087 Buildings and grounds
All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above as LPA observed an old bed spring and matresses placed outside by food pantry which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licnesee to clear all passageways and send proof to LPA 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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
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