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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005775
Report Date: 11/07/2022
Date Signed: 11/07/2022 02:05:26 PM


Document Has Been Signed on 11/07/2022 02:05 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BABB STREET MANORFACILITY NUMBER:
306005775
ADMINISTRATOR:MCKEEVER, SEANFACILITY TYPE:
740
ADDRESS:2959 BABB STTELEPHONE:
(562) 207-7216
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 5DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Maria McKeeverTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Babb Street Manor to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 12:55pm, LPA Cho was greeted and granted entry by Caregiver David Cesena Meza. Also present was Caregiver Jorge Topete. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a check-in station but temperatures of visitors were not documented on the sign-in sheet. LPA observed the required COVID-19 precautionary signs posted on the front entrance and throughout the facility. The Complaint Poster (PUB475) met the Department size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for six. There are currently five residents living in the facility of which two are receiving hospice care. Licensee Maria McKeever arrived at the facility approximately 1:25pm.

At 1:13pm, LPA Cho conducted a tour of the physical plant with Licensee McKeever and Caregiver Meza. There are a total of five resident bedrooms and four resident bathrooms. There is a private staff bedroom and bathroom. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and slip mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked with hand soaps and paper towels. LPA observed hand washing signs in the bathrooms. The hot water temperature in the resident bathrooms measured at 117.6 degrees Fahrenheit in resident Bathroom #1, 117.5 degrees Fahrenheit in resident Bathroom #2, 117.3 degrees Fahrenheit in Bathroom #3, and 116.7 degrees Fahrenheit in Bathroom #4. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and serviced on 11/24/2022. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BABB STREET MANOR
FACILITY NUMBER: 306005775
VISIT DATE: 11/07/2022
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LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. LPA was unable to test the exit gate due to a missing wire cord that allows the gate to self-close. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Licensee Maria McKeever, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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