197803185-5-23-2022-11-AS-JCAN-CEPT57-20220523142505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803185
Report Date: 05/23/2022
Date Signed: 05/23/2022 02:25:10 PM

Document Has Been Signed on 05/23/2022 02:25 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 VILLA		FACILITY NUMBER:	197803185
ADMINISTRATOR:	MAX IGLESIAS		FACILITY TYPE:	740
ADDRESS:	269 EAST SAN ANTONIO DRIVE		TELEPHONE:	(562) 595-9886
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY: 6		CENSUS: 5	DATE:	05/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:09 PM
MET WITH:	ADMINISTRATOR MAX IGLESIAS		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/23/2022 at 12:00 NOON, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at Country Club Villa Facility. LPA Calderon was allowed entry into the facility by Administrator Max Iglesias. The facility is licensed for six residents age 60 and over of which (5) non- ambulatory residents. Currently, there are (5) residents residing in the facility, all over the age of 60, of which (5) are non- ambulatory care. LPA Calderon explained to Max Iglesias, the purpose of the 1-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: (3) resident service records, (3) resident medication records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 05/02/2022. The one-story residential home consists of (5) resident bedrooms, (4) resident bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, front yard, backyard with umbrella with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage. Staff are following modified diets as prescribed by doctors’ orders.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY CLUB VILLA	FACILITY NUMBER: 197803185
	VISIT DATE: 05/23/2022

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 106 degrees Fahrenheit. Facility (1) Carbon Monoxide and (8) Smoke Detectors hard wired and connected were tested and are working properly. The facility (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Three (3) resident files were reviewed and found to be complete. LPA Calderon reviewed (3) resident medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. The facility does not handle resident's money/cash resources. All the required documents are posted in the facility in a clearly visible area. .
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Max Iglesias.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC809 (FAS) - (06/04)

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