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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603340
Report Date: 09/05/2023
Date Signed: 09/05/2023 04:54:10 PM


Document Has Been Signed on 09/05/2023 04:54 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:FIDLER COTTAGEFACILITY NUMBER:
198603340
ADMINISTRATOR:AVILA, GLENDAFACILITY TYPE:
740
ADDRESS:2874 FIDLER AVETELEPHONE:
(424) 241-4625
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 6DATE:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Samuel Manalo, AdministratorTIME COMPLETED:
04:58 PM
NARRATIVE
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On 09/05/23 Licensing Program Analyst (LPA) conducted an unannounced annual required inspection of the above mentioned facility, using the CARE Inspection Tool. LPA met administrator, Samuel Manalo, and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above, of which one may be bedridden in RM #4. Currently, the facility has (1) hospice resident in care. The facility is approved for (2) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: Five (5) residents' rooms, two (2) bathrooms (one of which is used for staff), one (1) staff room located in the garage, a living area, a dining area, a kitchen, an outside shaded seating area and a garage.

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 resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 116.3 degrees F. A comfortable temperature 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 residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Three fire extinguishers were charged, as of July 31st, 2023.

A review of the Medication Administration Record will be conducted during the next, unannounced, continuation of this annual inspection.

There has been two deficiencies cited, please see LIC809D.
An exit interview was conducted with Administrator, Samuel Manalo, and a copy of this report along with appeal rights have been provided via email.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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 09/05/2023 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: FIDLER COTTAGE
FACILITY NUMBER: 198603340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2023
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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Administrator, Samuel Manalo, will take Lorna Tabudlong (Staff 3 - S3) for a fingerprint session, in order to receive criminal clearance prior to S3 returning to work at this facility.

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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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2023 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: FIDLER COTTAGE
FACILITY NUMBER: 198603340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 in displaying three (3) out of five(5) stove burners not being able to light via knobs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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LPA and Admnistrator, Samuel Manalo, have agreed that the facility will maintain the electronic ignitor system within the kitchen stove burners on, or prior to, the POC due date which is 09/19/23 and will submit evidence to LPA through email at Mario.Leon@DSS.CA.GOV.
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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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