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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320262
Report Date: 05/02/2025
Date Signed: 05/02/2025 03:33:45 PM

Document Has Been Signed on 05/02/2025 03:33 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:FLORESMA GUEST HOMEFACILITY NUMBER:
198320262
ADMINISTRATOR/
DIRECTOR:		SERRANO, CARLFACILITY TYPE:
740
ADDRESS:1812 E. HARDWICK AVETELEPHONE:
(562) 895-2418
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 5DATE:
05/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:13 AM
MET WITH:Myrna MaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On May 2, 2025, Licensing Program Analyst (LPA), Deborah Lee conducted an unannounced annual required visit using the CARE Inspection Tool. LPA Lee met with Myrna Ma and the purpose of today’s visit was explained. The facility is licensed to serve six (6) residents, all of which (6) may be non-ambulatory with a hospice waiver approved for four (4) aged 60+ years.

The Annual Licensing Fees are current.

Physical Plant/Structure :

The one-story residential home consists of four (4) resident bedrooms, one (1) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. The facility is clean, sanitary, and in good repair.

Licensee accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: FLORESMA GUEST HOME
FACILITY NUMBER: 198320262
VISIT DATE: 05/02/2025
NARRATIVE
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Bedrooms:

LPA inspected all 4 bedrooms; the mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked.

Bathrooms:

Resident bathroom was checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid material was in place, hot water temperature properly measured 114 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common Rooms

Common areas were clean and clear of hazards, doorways were free of obstructions.

First Aid kit was available. 3 fire fully charged fire extinguishers were observed in the kitchen area, the living room area. Staff tested smoke/carbon monoxide detectors they were operational.

Required Postings:

LPA observed all required documents posted throughout the facility.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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: FLORESMA GUEST HOME
FACILITY NUMBER: 198320262
VISIT DATE: 05/02/2025
NARRATIVE
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Kitchen:

LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. Knives and toxins were kept locked and inaccessible to residents in care.

Safety:

LPA observed 3 fully charged fire extinguishers . Emergency disaster plan updated 5/2/25. Smoke detectors/Carbon monoxide detector tested and is operational.

File Review: LPA reviewed ( 5 ) resident files and found that ( 5 ) out of (5 ) had the required documents. LPA reviewed ( 4 ) staff fields and found that ( 3 ) out (4) had the required documents, training, and certifications. The 3 out of 4 needed to update CPR/First Aid.

Medications LPA observed all centrally stored medications secured. All medications were observed in their original packaging.

LPA reviewed a copy of the facility’s Liability Insurance which expires on 4/29/2026

During today’s visit there were no deficiencies issued. There was Technical Advisory note issued. See LIC 9102.

An exit interview was conducted with Myrna Ma and a copy of this report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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