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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607285
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:49:12 AM

Document Has Been Signed on 11/15/2022 11:49 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LONGWORTH HOMEFACILITY NUMBER:
197607285
ADMINISTRATOR:LIBERTY VENTURAFACILITY TYPE:
740
ADDRESS:16439 LONGWORTH AVENUETELEPHONE:
(714) 720-8069
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator - Peter VenturaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required – 1 Year Inspection and met with caregiver Jeanette Ordonez to discuss purpose of today's visit.

During the inspection LPA Calderon observed 4 clients present and 2 staff were present in the facility during this inspection. LPA Calderon and Felicidad Angeles toured the physical plant. The home consists of 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, kitchen, dining room and living room and backyard. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards, doorways were free of obstructions.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably, clean and sanitary conditions. There are no security bars or weapons on the premises. Bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Bathroom #1 hot water temperature measured at 116.7 F and bathroom #2 measured at 116.3 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Chemicals were found in both restrooms accessible to clients, deficiency was cited. See 809D

LPA toured the kitchen area and observed more than two-day supply of perishable and more than seven-day supply of non-perishable food. Knives were kept in locked storage cabinet. Kitchen water measured at: 115 F.

At 10:45 PM LPA Calderon met with Peter Ventura tested carbon monoxide detector and smoke detector located in the living room area. Both devices were functional.

LPA Calderon observed two employee files and four resident medication and Medication Log. Medication was observed locked. Medication Record and prescribed medication error was found, deficiency cited. See 809D.

Continuation 809C..

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LONGWORTH HOME
FACILITY NUMBER: 197607285
VISIT DATE: 11/15/2022
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LPA Calderon observed Covid-19 symptom screening log and PPE readily available at the entrance of the home. Home has PPE for 30 plus days and Infection Control Tool was completed.

An exit interview was conducted and copy of this report 809, 809C , 809D and appeal rights were provided and given to Administrator Peter Ventura.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
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Document Has Been Signed on 11/15/2022 11:49 AM - It Cannot Be Edited


Created By: Ashley Calderon On 11/15/2022 at 11:06 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LONGWORTH HOME

FACILITY NUMBER: 197607285

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having chemicals and disinfectants inaccessible to 4 out of 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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Administrator Peter Ventura, stated he will provide training to staff on following regulations in regards to properly storing chemicals, disinfectants and cleaning solutions in locked areas inaccessible to residents and will provide documentation to LPA. LPA Calderon observed staff placing chemicals in locked cabinets inaccessible to residents.
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observed , the licensee did not comply with the section cited above in having assist residents 1 out of 4 with medication and taking dosage needed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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Administrator Peter Ventura, stated he will provide training to staff on following regulations in regards to staff properly documenting and distributing medications to residents who shall assist residents who are unable to self-administor. Ventura will provide documentation to LPA. LPA Calderon observed Ventura calling House Manager, Sarah Levante in regards to medication error. Facility will contact residents PCP for further instructions.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022


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