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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603340
Report Date: 09/30/2024
Date Signed: 09/30/2024 10:57:15 AM


Document Has Been Signed on 09/30/2024 10:57 AM - 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:
09/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Kian PascualTIME COMPLETED:
11:00 AM
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On September 30, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced Case Management Continuation visit for the purpose of completing the Annual required inspection started on September 25, 2024. LPA met with Kian Pascual back up Administrator and explained purpose of today's 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 waivers. There are currently 6 residents in care.

During today’s visit LPA reviewed the following:

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked closet that is inaccessible to Residents in care.

Files LPA reviewed (5) resident files and found (5 ) out of (5 ) contained all the necessary documentation: Admission Agreement, Medical Assessments, Consent forms, ID, TB tests, Personal Rights, and Appraisal/Needs and Services plan. LPA reviewed four (4 ) staff files and found (4) out of ( 4 ) contained the required documentation, certification, and training. Liability Insurance expires on 11/14/2024.

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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: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024
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: 09/30/2024
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Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper towels, cleaning, and disinfecting supplies were observed.

There were no deficiencies cited during today’s visit.

An exit interview was conducted with Kian Pascual and a copy of this report was provided.

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

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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