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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803185
Report Date: 06/03/2021
Date Signed: 06/03/2021 01:10:50 PM

Document Has Been Signed on 06/03/2021 01:10 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:COUNTRY CLUB VILLAFACILITY NUMBER:
197803185
ADMINISTRATOR:MAX IGLESIASFACILITY TYPE:
740
ADDRESS:269 EAST SAN ANTONIO DRIVETELEPHONE:
(562) 595-9886
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 5DATE:
06/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:ADMINISTRATOR MAX IGLESIASTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by licensee Max Iglesias and the purpose of today’s visit was explained. The facility is licensed to serve 6 elderly 59 and older.

There are currently 5 elder residents in care. All 5 residents are non-ambulatory, and 4 residents have dementia. The facility is a 1-story structure with 5 bedrooms and 4 bathrooms, living room, kitchen and inside and outside patio.

LPA Calderon and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were locked up and not accessible to clients. Smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2021
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COUNTRY CLUB VILLA
FACILITY NUMBER: 197803185
VISIT DATE: 06/03/2021
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there was no deficiencies under California code of regulation title 22, division 6, chapter 8.

Exit interview held and appeal rights provided. A copy of the report was provided to licensee Max Iglesias.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC809 (FAS) - (06/04)
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