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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602622
Report Date: 08/03/2024
Date Signed: 08/03/2024 04:47:37 PM

Document Has Been Signed on 08/03/2024 04:47 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/
DIRECTOR:		NJOROGE, PRISCILLAHFACILITY TYPE:
735
ADDRESS:3947 N. MARSHALL WAYTELEPHONE:
(562) 290-8639
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 3CENSUS: 2DATE:
08/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:46 AM
MET WITH:Edgar Arana - Administrator TIME VISIT/
INSPECTION COMPLETED:
03:47 PM
NARRATIVE
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On 08/03/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met administrator Edgar Arana. LPA explained the purpose of today’s visit. The facility is licensed to operate for (3) non-ambulatory of which maybe (1) bedridden adults 18 through 59. The residents are all Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (3) client's rooms, (2) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage and an office.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 108.7 degrees F. A comfortable temperature of 73 F. degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguishers were charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 06/21/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current Liability Insurance effective 07/01/24 - 07/01/25 and a Surety Bond effective 06/28/17 on file.
(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2024
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 08/03/2024 04:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/03/2024 at 02:10 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: 08/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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. Staff #1 did not have First Aid/CPR certificate on file. This violation which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 08/17/2024
Plan of Correction
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Licensee/Administrator will ensure all facility staff must have the mandatory First Aid/CPR Training completed. As plan of correction, administrator will send proof of completed First Aid/CPR will be sent to LPA via email: ernand.dabuet@dss.ca.gov before POC due date 08/17/24.
Type B
Section Cited
CCR
80066(a)(10(11)
(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 80065(g). (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. Staff #1 did not have a health screening nor TB test results on file. This violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2024
Plan of Correction
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Licensee/Administrator will ensure all facility staff have completed a Health Screening LIC 503 and TB test results. As plan of correction, administrator will send proof of Health Screening LIC503 with TB test results to LPA via email: ernand.dabuet@dss.ca.gov before 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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2024 04:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/03/2024 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
, 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: 08/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(4)
(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 Staff #4 associated at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2024
Plan of Correction
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Licensee/Administrator will ensure all facility staff are associate at the facility. As plan of correction, administrator will associate staff #4 and proof of association will be sent to LPA via email: ernand.dabuet@dss.ca.gov before POC due date of 08/04/24. **This violation was corrected during visit***
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2024


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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: 08/03/2024
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, and 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.

An audit of clients #1-#2 (C1-C2) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. The facility has the current administrator's certification on file for Edgar Arana expiration date 0704/25 #7018542735.

Deficiencies:
  • Staff #1(S1) did not have a First Aid/CPR certificate, Health Screen LIC 503, and TB Test results on file.
  • Staff #4 (S4) was identified without Criminal Record Transfer LIC 9062 on file.


Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 1,

Deficiencies are issued and an exit interview is conducted with Edgar Arana. A copy of this report and appeal rights.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *


SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2024
LIC809 (FAS) - (06/04)
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