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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603340
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:34:22 PM


Document Has Been Signed on 09/25/2024 03:34 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: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:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Kian PascualTIME COMPLETED:
03:45 PM
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On September 25, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with Kian Pascual, On call administrator and explained the purpose of this visit. The facility is licensed to operate for (6) non-ambulatory and 1 may be bedridden elderly residents ages 60 and above. The facility is approved for (6) hospice residents. There are currently 6 residents in care.

Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: ( 6) residents' rooms, ( 2 ) bathrooms, (1) staff room, a living area, a dining area, a kitchen, an outside seating area and an attached garage.

Physical Plant LPA and Kian Pascual toured the facility inside and outside. LPA observed 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. LPA observed that facility had required postings: ombudsman poster, see something say something poster, emergency numbers, clients rights, employee Federal/State wage information, facility sketch,

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SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah LeeTELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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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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: FIDLER COTTAGE
FACILITY NUMBER: 198603340
VISIT DATE: 09/25/2024
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Bedrooms LPA inspected all six (6) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, night stands, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. Resident’s toiletries are secured in a cabinet under the sink. The water temperature measured 111.6-degrees Fahrenheit. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets.

Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, and additional freezer. LPA observed an ample supply of cutlery, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked drawers in the kitchen and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. Cleaning products and toxins were secured in hall closet that is inaccessible to clients.

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SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah LeeTELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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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: FIDLER COTTAGE
FACILITY NUMBER: 198603340
VISIT DATE: 09/25/2024
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Common Rooms In the living room, LPA observed to have 5 recliners, mounted TV. In the dining room, LPA observed a six seated dinning table.

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed ( 2 ) fully charged fire extinguisher mounted on the wall, last serviced on 8/9/2024. The last emergency drill was conducted on 9/10/2024. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, guaze, disinfectant wipes, band aids and a manual. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises.

LPA informed Administrator of their annual fees status.

Due to time constraints, LPA to complete inspection on a subsequent visit.

There were no deficiencies cited during today’s inspection.

Exit interview conducted and copy of this report given to Kian Pascual

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SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah LeeTELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3