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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320237
Report Date: 11/04/2021
Date Signed: 11/04/2021 11:48:30 AM

Document Has Been Signed on 11/04/2021 11:48 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:ALOHA GARDENS SENIOR WELLNESS HOMEFACILITY NUMBER:
198320237
ADMINISTRATOR:STONE, DARYLLENFACILITY TYPE:
740
ADDRESS:2214 CONQUISTA AVENUETELEPHONE:
(562) 900-5208
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 0DATE:
11/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Darlynn StoneTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Jade Jordan, Ngozi Nwokoro made an announced, and met with the Licensee Darlleyn Stone to conduct a Pre-Licensing evaluation on Thursday, November 4, 2021, at 10:00 am.

An application was submitted to Community Care Licensing Department (CCLD) on 08/11/2021 for an initial application to serve Individuals for the ages 60 years old, and older. The requested capacity is for one (1) non-ambulatory clients, four (4) ambulatory clients, and one (1) bedridden clients, a total capacity of six (6). Structure: The facility is a one-story family home in a residential neighborhood. There is a family room, living room, Detached Garage, administrative office, laundry room, 2 common bathrooms, (both of which is wheelchair accessible), kitchen, and backyard, 5 bedrooms, and 1 room designated for staff. Bedroom Residents: There shall be no more than two clients per bedrooms. Bedrooms #1,3,5 are for ambulatory clients, Bedroom #2 is for non-ambulatory client, Bedroom #4 Bedridden. Bedrooms are equipped with one bed, nightstand, chair, lamp, and overhead lightning. Bedroom Staff: No bedrooms are used for live in staff. Bathrooms: Two (2) common bathrooms have a working toilet, showers with skid mat, and grab bars. Both bathrooms that will accommodate non-ambulatory clients in a wheelchair. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Ample supply of linen is stored in the front cabinet.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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: ALOHA GARDENS SENIOR WELLNESS HOME
FACILITY NUMBER: 198320237
VISIT DATE: 11/04/2021
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. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in office area. Facility is still waiting on a land line telephone. Two (2) fully charged fire extinguishers are located in hall , and and backdoor, serviced on 09/17/21. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored. Ample food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Smoke Detectors/Carbon Monoxide(s): There are (12) Hard wire electrical smoke detectors with connected carbon monoxide; located in bedrooms, the family room, office, kitchen, and outside patio: all are fully operational. Appliances: Stove burners (gas or electric), oven, dishwasher, microwave, and washer/dryer are in working condition. There is one (1) refrigerators in the facility; located in the kitchen, it is in brand new working condition. The facility is equipped with central heat/air conditioning. Toxins: Cleaning supplies, and toxins will be stored in a locked cabinet in the kitchen, only accessible to staff. Water Temperature: Hot water was tested in bathroom #1, and temperature was 116.2 degrees which is within normal limits (105-120 degrees). Medication, First-Aid Kit & Book: Designated centrally stored medication will be locked and located in medication cabinet in kitchen. 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 office file cabinet. Applicant will not handle cash resources of clients. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 09/17/21 does advise of any delayed egress features and/or any locked perimeters.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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: ALOHA GARDENS SENIOR WELLNESS HOME
FACILITY NUMBER: 198320237
VISIT DATE: 11/04/2021
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Component III:
Component III was completed at the Pre-Licensing on Thursday, 11/04/2021 at 11:30 am. Information provided about how to operate the facility within substantial compliance. The following individuals, Ella, Administrator participated. When the applicant and administrator were asked if they have understood Title 22 they responded in the affirmative.

During the pre-licensing inspection there was one item observed which did 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 11/10/21. 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. Landline Telephone

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: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC809 (FAS) - (06/04)
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