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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320107
Report Date: 09/18/2024
Date Signed: 09/18/2024 02:40:09 PM

Document Has Been Signed on 09/18/2024 02:40 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:OAKTREE MANORFACILITY NUMBER:
198320107
ADMINISTRATOR/
DIRECTOR:		DADABHOY, MUQEETFACILITY TYPE:
740
ADDRESS:3269 SAN ANSELINE AVETELEPHONE:
(310) 251-2382
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 2DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Edilberto Bernardino, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On September 18, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with Edilberto Bernardino Assistant Administrator and Alvin Ramos House Manager and explained the purpose of this visit. The facility is licensed to operate for (6) ambulatory and (6) bedridden elderly residents ages 60 and above. The facility is approved for (6) hospice residents. There are currently 2 residents in care.

Structure: The facility is a single-story structure located in a residential neighborhood. It consists of the following: ( 6) residents' rooms, ( 3 ) bathrooms, (1) staff room, a living area, a dining area, a kitchen, an outside seating area and an attached garage. The construction that was documented in annual visit conducted on 11/30/2023 is in the completed phase. The garage door will be completed by the end of the week per House Manager.

Physical Plant LPA and Edilberto Bernardino toured the facility inside and outside. LPA observed There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OAKTREE MANOR
FACILITY NUMBER: 198320107
VISIT DATE: 09/18/2024
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 LPA observed the facility had required postings: ombudsman poster, see something say something poster, emergency numbers, clients rights, employee Federal/State wage information, facility sketch menus, disaster plan.

Bedrooms LPA inspected all six (6) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. Resident’s toiletries are secured in a cabinet under the sink. The water temperature measured 111-degrees Fahrenheit. The visitor bathroom was observed to be clean. The toilet and faucets are operational. All bathrooms in the facility were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OAKTREE MANOR
FACILITY NUMBER: 198320107
VISIT DATE: 09/18/2024
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Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, and additional freezer. LPA observed an ample supply of cutlery, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked drawer in the kitchen and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. Cleaning products and toxins were secured in hall closet that is inaccessible to clients.

Common Rooms In the living room, LPA observed sofa, love seat, 3 recliners, mounted TV and a piano. In the dining room, LPA observed a six seated dinning table and a huge Island area counter with seating for six.

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed ( 2 ) fully charged fire extinguisher mounted on the wall, last serviced on 10/20/2023. The last emergency drill was conducted on 9/13/2024. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, guaze, disinfectant wipes, band aids and a manual. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises.

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked closet that is inaccessible to Residents in care. Medications observed to be in original packaging with appropriate labels.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OAKTREE MANOR
FACILITY NUMBER: 198320107
VISIT DATE: 09/18/2024
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Files LPA reviewed (2) resident files and found the contained all the necessary documentation. LPA reviewed four (4) staff files and found they contained the required documentation, certification, and training. Liability Insurance expires on 06/30/2025

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper towels, cleaning, and disinfecting supplies were observed.

There were no deficiencies cited during today’s visit.

An exit interview was conducted with Assistant Administrator Edilberto Bernardino and a copy of this report was provided.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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