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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320237
Report Date: 11/09/2022
Date Signed: 11/09/2022 04:52:17 PM

Document Has Been Signed on 11/09/2022 04:52 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, 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: 6DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Anchie ReyesTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Mario Leon made an unannounced inspection to Aloha Gardens Senior Wellness Home Facility. The purpose of today’s visit was to conduct an Annual inspection with a primary focus on infection control measures. During today’s visit, LPA Leon met with Lead caregiver / Assistant Administrator Anchie Reyes and the reason for the visit was explained. The facility has a capacity of 6 clients. The facility currently has 6 clients.

LPA Leon toured the facility along with caregiver Anchie Reyes. The home consists of 4 client bedrooms, 2 bathrooms, 1 staff office and 1 staff room, living room, Kitchen, dining area and laundry room. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation and both had adequate equipment for physically handicapped clients. Toilets and water faucets worked properly. Showers were free of mold/mildew, adequate lighting, and sufficient toiletries were accessible to clients. Water temperature was properly measured at 108.6 degrees F in the kitchen, and 119.1 F in bath #1.

Non-perishable and perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detectors were operational. Smoke detectors were working properly, 3 fire extinguishers were fully charged and operational, toxins and sharps were locked and inaccessible to clients. Medications were locked and inaccessible to clients, first aid kit was checked and in order. Outside grounds were toured and no bodies of water were observed. Shaded area in backyard, with fire pit, was accessible. Exits/ Walkways around the home were free of debris and hazards.

See LIC809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ALOHA GARDENS SENIOR WELLNESS HOME
FACILITY NUMBER: 198320237
VISIT DATE: 11/09/2022
NARRATIVE
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During the visit, LPA Leon observed the facility infection control practices. LPA Leon observed screening protocols for visitors, staff and residents, hand sanitizer was available in every room as well as every outdoors region. LPA observed staff were wearing face coverings, an isolation room and required postings were throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Lead caregiver to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there was one (1) deficiency observed, see LIC809D.

Exit interview held. A copy of the report was provided to Anchie Reyes.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/09/2022 04:52 PM - It Cannot Be Edited


Created By: Mario Leon On 11/09/2022 at 04:48 PM
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: ALOHA GARDENS SENIOR WELLNESS HOME
FACILITY NUMBER: 198320237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Leon's observation, the licensee did not comply with the section cited above in Personnel Records/Staff Training - Type A: 87355(e) - Anchie Reyes has not been associated with Aloha Gardens Senior Wellness home which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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Anchie Reyes has agreed to learn the Guardian system and update the facility roster at Aloha Gardens Senior Welllness Home.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
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