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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320107
Report Date: 09/18/2022
Date Signed: 09/18/2022 11:14:17 AM

Document Has Been Signed on 09/18/2022 11:14 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:OAKTREE MANORFACILITY NUMBER:
198320107
ADMINISTRATOR:DADABHOY, MUQEETFACILITY TYPE:
740
ADDRESS:3269 SAN ANSELINE AVETELEPHONE:
(310) 251-2382
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 5DATE:
09/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Muqueet DadabhoyTIME COMPLETED:
11:31 AM
NARRATIVE
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On 09/18/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Muqeet Dadabhoy and explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory and may be (6) bedridden elderly residents ages 60 and above. The facility is approved for (6) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) residents' rooms, two (2) common bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, and an outside patio area.

LPA toured the physical plant with Dadabhoy. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be operational. The water temperature measured 108.6 F. A comfortable temperature of 74 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers are fully charged, and smoke detectors operable. A working landline telephone remains available. A review of Medication Administration Records and Fire Drill are maintained and in order. The last fire drill was conducted on 09/03/22.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/18/2022 11:14 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/18/2022 at 10:13 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKTREE MANOR
FACILITY NUMBER: 198320107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the license did not comply with the section cited above and LPA identified rear stove burner not working and must use a match to light burner. This vioilation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2022
Plan of Correction
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The licensee will adhere to Title 22 8755(b)(2). The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. The licensee will repair stove rear burner send proof of correction with service receipt and photo. Plan of correction will be submitted by POC due date: 10/09/22
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2022


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Document Has Been Signed on 09/18/2022 11:14 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/18/2022 at 10:27 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKTREE MANOR
FACILITY NUMBER: 198320107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 LPA identified (3) items: sharp scissors, gardening shears, cleaning dissefectant exposed to residents in care. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2022
Plan of Correction
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The licensee will adhere to Title 22 87705. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. The licensee to must ensure all hazardous items are stored in locked storage cabinets at all times. POC must be sent to LPA by 09/19/22.
This was corrected during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2022


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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OAKTREE MANOR
FACILITY NUMBER: 198320107
VISIT DATE: 09/18/2022
NARRATIVE
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INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

DEFICIENCIES:
LPA identified the 9:25 am kitchen stove rear burner not working. At 9:27 am LPA identified a sharp scissor in bathroom #1 and bathroom #2 had a disinfectant cleaning solution under the cabinet sink. At 9:30 am LPA identified gardening shears laying on a small outdoor table adjacent to the garage accessible to residents in care.

Deficiencies are issued and an exit interview is conducted with house manager Chrisela De Leon. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2022
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