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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003625
Report Date: 09/04/2024
Date Signed: 10/04/2024 02:29:41 PM

Document Has Been Signed on 10/04/2024 02:29 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:AQUARIUS HOMEFACILITY NUMBER:
306003625
ADMINISTRATOR/
DIRECTOR:		LOURDES ORDONEZFACILITY TYPE:
735
ADDRESS:1765 W. AQUARIUS STTELEPHONE:
(562) 427-6260
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 4CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:58 PM
MET WITH:Valenczar Aguirre, Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 09/04/2024 at 1:45pm , LPA Zina Brown conducted an unannounced continuation annual visit using the CARE Inspection Tool. LPA met with the Valenczar Aguirre, Administrator Designee and the purpose of today’s visit was explained.

LPA conducted a records review of (4) client records, (7) staff records, (4) clients Personal & Incidental Records and (3) client medications administration records. All client records were complete & all staff records were incomplete. LPA reviewed (3) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

LPA observed the following not in compliance:
On 09/04/2024, LPA conducted a file review of staff files and did not observe an update CPR/first aid for all employees

  • no staff training for Staff #1 - Staff #7 from 2022 - 2024.
  • Staff #1 Adult Residential Facility Certification last completed on 02/15/2020 and expired on 02/14/2022.
  • Also P & I did not match the the exact written amount on file for
    Client #3 ($99.84 - cash on hand, on written P & I form $114.89 which short $15.05)
    Client # 4 ($702.24 - cash on hand, on written P & I form $717.24 which short $15.00)

Deficiencies Cited Under California Code of Regulations Title 22, Division 6, Chapter 1.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: AQUARIUS HOME
FACILITY NUMBER: 306003625
VISIT DATE: 09/04/2024
NARRATIVE
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Exit interview conducted with Valenczar Aguirre, Administrator Designee and a copy of the report and the appeal rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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Page: 2 of 4
Document Has Been Signed on 10/04/2024 02:29 PM - It Cannot Be Edited


Created By: Zina Brown On 09/04/2024 at 04:58 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: AQUARIUS HOME
FACILITY NUMBER: 306003625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)1
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the administrator designee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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The adminstator shall submit proof of update Adult Residential Facility Certification by POC date to the department by email at Zina.Brown@dss.ca.gov
Type B
Section Cited
CCR
80075(f)
(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, LPA did not observe documents complete First Aid/CPR training for 2024.
POC Due Date: 09/18/2024
Plan of Correction
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The adminstator shall submit proof of completed First Aid/CPR training for all staff to the department by email at zina.brown@dss.ca.gov by 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:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


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Document Has Been Signed on 10/04/2024 02:29 PM - It Cannot Be Edited


Created By: Zina Brown On 09/04/2024 at 05:07 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: AQUARIUS HOME
FACILITY NUMBER: 306003625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(b)
If such a client is accepted for or maintained in care, his/her cash resources, personal property, and valuables not handled by a person outside the facility who has been designated by the client or his/her authorized representative shall be handled by the licensee or facility staff, and shall be safeguarded in accordance with the requirements specified in (c) through (n) below.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 2 out 4 clients P & I records did not match, cash on hand at the facility. Client #3 ($99.84 - cash on hand, on P & I form has $114.89 which is short $15.05) & Client # 4 ($702.24 - cash on hand, on P & I form has $717.24 - which short $15.00) the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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The administrator will ensure the balance document will match the cash on hand on the P& formI. Also the adminstrator will provide P & I training to all staff and send proof to the department at zina.brown@dss.ca.gov by POC Date.
Type B
Section Cited
CCR
1562(a)
(a) The department shall ensure that operators and staffs of community care facilities have appropriate training to provide the care and services for which a license or certificate is issued. The section shall not apply to a facility licensed as an Adult Residential Facility for Persons with Special Health Care Needs pursuant to Article 9 (commencing with Section 1567.50).

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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The adminstrator will provide training for all staff by POC due date and sent proof of completed training to the department at zina.brown@dss.ca.gov by 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:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


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