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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320199
Report Date: 09/09/2021
Date Signed: 09/09/2021 11:58:23 AM

Document Has Been Signed on 09/09/2021 11:58 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:KEEN HOME LONG BEACHFACILITY NUMBER:
198320199
ADMINISTRATOR:DUTILE, VIRGINIA (GINNY)FACILITY TYPE:
740
ADDRESS:6441 BIXBY HILL RDTELEPHONE:
(562) 438-5336
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY: 6CENSUS: 0DATE:
09/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dawn Michelle ThompsonTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPA) Jade Jordan, made an announced visit, and met with the Applicant/ Administrator Dawn Michelle Thompson, and Virginia " Ginny" Dutile to conduct a Pre-Licensing evaluation on Thursday September 09th, 2021, at 10:00 am.

An application was submitted to Community Care Licensing Department (CCLD) on 02/17/2021 for an initial application to serve Individuals over ages 60 years and above. The requested capacity is for six (6) of which Five (5) can bed ridden clients, and one (1) Non -ambulatory client. Structure: Facility is a one story family home with six (6) bedrooms, (2) full bathrooms, and 1 half (1/2) bathroom. There is an open spaced living room, den, and kitchen. Washer/Dryer appliances are located in storage space located to the right side of the kitchen. A three (3) car garage is located in the front of the property, and will be used for storage/ office space , and Physical therapy inaccessible to residents. Front yard landscape under construction during the time of visit. Bedroom Residents: There shall be no more than two residents per bedrooms. Bedrooms #1- 6, are private Bedrooms, and #2-6 are for (5) bedridden clients. Bedrooms are equipped with one bed, night-stand, chair, and overhead lightning. Bedroom 1-3 are towards the front left side of the house, and bedroom 4 -5 are located in the left back side of the house, bedroom # 6 is located on the right backside of the house towards the den.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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: KEEN HOME LONG BEACH
FACILITY NUMBER: 198320199
VISIT DATE: 09/09/2021
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 Bedroom Staff: There will be no live-in staff, there will be (3) Shifts . Bathrooms: Three (3) bathrooms have a working toilet, and wash basin, 2 of the bathrooms (2) have showers. Skid Mats and Grab Bars in place. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads, all rooms have required mattress pads. Ample supply of linen is stored in the closet hallway. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted in the kitchen, and menu will be posted on breakfast bar. Facility has a land line telephone located in the kitchen and living room area, currently active. There are three (3) fully charged fire extinguishers. Food Service: Dishes, and flatware are stored in the kitchen cupboards, inspected and in good repair, Knives, cutlery, and other sharp kitchen utensils will be stored right hand side cabinet next to kitchen sink. Ample food supply is stored in the kitchen and consists of the following: 7-day non-perishables. Dishwasher in kitchen properly installed and functioning. Smoke Detectors/Carbon Monoxide(s): There are 8 electrical & connected smoke detectors with carbon monoxide; located throughout the facility, and fully operational. Appliances: Stove burners (gas) oven, dishwasher, microwave, and washer/dryer are in working condition. There are two (2) refrigerator in the home; located in the kitchen, and garage. The residence is equipped with central heat/air conditioning. Toxins: Cleaning supplies, and toxins will be located in locked kitchen cabinet only accessible to staff. Water Temperature: Hot water was tested in bathroom # 2 at 106.d which is within normal limits (105-120 degrees). Medication, First-Aid Kit & Book: Designated centrally stored medication will be locked and located in the locked kitchen cabinet , Sufficient bandages, one (1) tweezer, one (1) thermometer, one (1) First Aid Manual, and one (1) pair of scissors. Clients & Staff Files: Designated area for files will be located in locked file cabinet, located in the garage. Applicant will not handle cash resources of clients. Reading Material, Games, Equipment & Materials: The facility has bingo , puzzles, paints, and other recreational materials for the client's use. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 06/03/2021 does not advise of any delayed egress features and/or any locked perimeters.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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: KEEN HOME LONG BEACH
FACILITY NUMBER: 198320199
VISIT DATE: 09/09/2021
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Component III:
Component III was completed at the Pre-Licensing on Thursday, 09/09/2021. Information provided about how to operate the facility within substantial compliance. The following individuals Dawn Michelle Thompson Licensee, and Virginia (Ginny) Dutile Administrator participated. When the applicant /administrator was asked if they have understood Title 22 they responded in the affirmative.

During the pre licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA by 09/13/2021. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.



1. Front Landscaping ( Completed Construction)
2. Back Landscaping ( Completed Construction)
3. Tools removed from Bedroom #5

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau(CAB ) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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