198603340-9-8-2021-11-AS-JJON-C6NUYS-20210908160024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603340
Report Date: 09/08/2021
Date Signed: 09/08/2021 04:00:40 PM

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:	FIDLER COTTAGE		FACILITY NUMBER:	198603340
ADMINISTRATOR:	AVILA, GLENDA		FACILITY TYPE:	740
ADDRESS:	2874 FIDLER AVE		TELEPHONE:	(424) 241-4625
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 6	DATE:	09/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Veahlou Allaine Dealto Caregiver		TIME COMPLETED:	04:00 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 09/08/21 Licensing Program Analyst (LPA) Jade Jordan conducted an annual inspection, with an emphasis on inspection control. Lpa was met by Staff Veahlou Allaine Daelto , and the purpose of the visit was explained. Upon entry Lpa was screen and filled out a questioner related to symptoms of Covid 19. The facility is a single story house with five (5) bedrooms, two (2) bathrooms, kitchen, living room, dining area, laundry area, a small back yard with tables and adequate chairs with covered patio and a detached garage. There's no bodies of water on the premises. All outdoor and indoor passageways are free of obstruction. Lpa observed all bedrooms to have the required furnishing which included a chair, dresser, bed, flat sheet , fitted sheets, and adequate lighting. Lpa observed one fire extinguisher, fully charged, and multiple smoke alarms which included carbon monoxide. All Smoke Alarms were working properly. The facility Staff could not recall the last dateof a performed fire drill. LPA advised Technical Advisory will be given. The kitchen was observed to be clean and toxins were locked. A minimum of 2 days of perishable food supply was observed. Technical Advisory issued for food and condiments not being labeled with expiration dates, and no 30 day supply of emergency water. The water temperature in the facility tested at 114.0 degree's which is within title 22 regulations. Lpa Reviewed staff, resident and medication files, all of which had the required documentation. Lpa observed in the detached garage a staff bed, and clothing. LPA advised that live in staff are not in the plan of operation, and there is no permit on file to inhabit the garage. Citations will be issued for plan of operation.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

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: FIDLER COTTAGE	FACILITY NUMBER: 198603340
	VISIT DATE: 09/08/2021

NARRATIVE

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Lpa observed all staff to be wearing mask while working with residents in care. Lpa observed a 30 day supply of gowns, gloves and N95 masks.

Technical Advisory's were given in the following areas:

Emergency water supply
Department of Public Health Phone Number Posting.
Fire drills to be completed
Light Bulb in Bathroom
Face shields

Before LPA left light bulbs were put in place, and DPH phone numbers were posted.

An exit interview was conducted and a copy of this report was given.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC809 (FAS) - (06/04)

Page: 2 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: FIDLER COTTAGE	FACILITY NUMBER: 198603340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87208 Plan of Operation (a)(5) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (5)Staffing plan, qualifications and duties.This standard was not met as evidence by: Licensed with no live in staff, Lpa Observed staff bed, and personal belongings in the garage. staff are sleeping there on their days off. This poses a potential health, safety and personal rights risk to residents in care.
	POC Due Date: 09/22/2021
	Plan of Correction
1 2 3 4	Licensee will submit a plan for live in staff; if licensee plans to convert garage to live in quarters needs to submit required permits.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC809 (FAS) - (06/04)

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