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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602622
Report Date: 02/17/2024
Date Signed: 02/17/2024 03:33:36 PM

Document Has Been Signed on 02/17/2024 03:33 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:EASTERSEALS SOUTHERN CALIFORNIA-MARSHALL RESIDENCEFACILITY NUMBER:
198602622
ADMINISTRATOR:NJOROGE, PRISCILLAHFACILITY TYPE:
735
ADDRESS:3947 N. MARSHALL WAYTELEPHONE:
(562) 290-8639
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 3CENSUS: 3DATE:
02/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Maria Drummond/AdministratorTIME COMPLETED:
03:33 PM
NARRATIVE
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On 2/17/2024 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Maria Drummond /Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (3) developmentally disabled or Mentally Ill adults ages 18-59 of which (3) may be non-ambulatory, of which (1) may be bedridden. Currently, the home has (3) clients. The clients are from: Harbor Regional Center. (1) clients have Restricted Health Care Conditions, and (1) are utilizing postural supports or protective devices. The staff to client ration: 2-3.

The one-story residential home consists of (3) resident bedrooms, (2) resident bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs.

LPA Iniguez and the house manager toured the inside and outside of the facility. LPA observed client rooms from afar since all clients were in quarantine. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees: (Kitchen 108.3°F, Bathroom #1 107.9°F and Bathroom #2 107.5°F).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 02/17/2024 03:33 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 02/17/2024 at 02:07 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: EASTERSEALS SOUTHERN CALIFORNIA-MARSHALL RESIDENCE
FACILITY NUMBER: 198602622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80061(b)(1)(H)


80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
(1) Events reported shall include the following:
(H) Epidemic outbreaks.
ment is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not reporting to CCLD the facility outbrake that affected all the clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Administrator will ensure to report any occurence to CCLD. As a plan of correction, administrator will submit an SIR to RO as soon as posible.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2024


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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: EASTERSEALS SOUTHERN CALIFORNIA-MARSHALL RESIDENCE
FACILITY NUMBER: 198602622
VISIT DATE: 02/17/2024
NARRATIVE
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Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, toxins and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last facility disaster drill was:2/12/23. The administrator gave a copy of Surety Bond to LPA during the visit.

LPA conducted a records review of (3) client records, (3) staff records. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit. The facility disaster plan was current and in compliance with Title 22 at the time of visit.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

- During evaluation LPA observed staff (S#1 and S#2) not following Infection Control Practices.

- Facility did not report outbreak to CCLD.

- S#2 did not have a TB test on file.

Civil Penalty Assessed:

-S#1 not associated to this facility.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Maria Drummond /Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/17/2024 03:33 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 02/17/2024 at 03:13 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: EASTERSEALS SOUTHERN CALIFORNIA-MARSHALL RESIDENCE
FACILITY NUMBER: 198602622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(b)(2)(B)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.  (B) PPE shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the assisting with direct care for each client.

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 LPA observed S#1 and S#2 not using and discarting PPE which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Administrator will ensure all facility staff is trained in the proper way of using PPE and discarting it. As plan of correction administrator will re-trained staff in the proper way to use PPE and discarting it. Administrator will send proof of training to LPA via email before POC due date.
Infection Control Requirements

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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/17/2024 03:33 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 02/17/2024 at 03:13 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: EASTERSEALS SOUTHERN CALIFORNIA-MARSHALL RESIDENCE
FACILITY NUMBER: 198602622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not having S#1 associated at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Administrator will ensure all facility staff is associate at the facility. As plan of correction , administrator will associate staff and proof of association will be sent to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 02/17/2024 03:33 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 02/17/2024 at 03:13 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: EASTERSEALS SOUTHERN CALIFORNIA-MARSHALL RESIDENCE
FACILITY NUMBER: 198602622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in missing for S#2 a TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Administrator will ensure all staff that works at the facility have a TB test on file. As plan of correction, administrator will sent proof of S#2 TB tes to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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2
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POC Due Date:
Plan of Correction
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2
3
4
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2024


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