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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601701
Report Date: 06/26/2022
Date Signed: 06/26/2022 03:41:14 PM

Document Has Been Signed on 06/26/2022 03:41 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:CITADEL HOMES, INC.FACILITY NUMBER:
198601701
ADMINISTRATOR:MARISSA G. MASHBURNFACILITY TYPE:
740
ADDRESS:1840 W. AQUARIUS STREETTELEPHONE:
(562) 426-8091
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 6CENSUS: 4DATE:
06/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH:Christopher Bundalian TIME COMPLETED:
11:59 AM
NARRATIVE
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On 06/26/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with assistant administrator Christopher Bundalian and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for two (2) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, three (3) common bathrooms, living area, dining area, kitchen, a staff room, an office and outside covered patio area.

LPA toured the physical plant. There were no obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured 109.9 degrees F. A comfortable temperature of 83 degrees was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and sufficient perishable and non-perishable food was maintained adequately. The facility has two (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. LPA reviewed Medication Administration Records (MAR) revealed to be accurate and maintained in order. A working landline telephone remains available.
Evaluation Report continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CITADEL HOMES, INC.
FACILITY NUMBER: 198601701
VISIT DATE: 06/26/2022
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DEFICIENCIES:
During the inspection visit at 9:10 am, LPA observed uncleaned and unsanitary microwave oven. At 9:16 am LPA observed a powder bleach on top of the bathroom sink accessible to residents in bathroom #2. At 9:17 am, LPA observed a non-working toilet in bathroom #2.

INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

Deficiencies are issued and an exit interview is conducted with Christopher Bundalian. A copy of this report is provided along with the appeal rights.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2022
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Page: 2 of 4
Document Has Been Signed on 06/26/2022 03:41 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/26/2022 at 11:19 AM
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: CITADEL HOMES, INC.
FACILITY NUMBER: 198601701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above cleaning solution powder bleach was observed on bathroom sink accessible to resident in care. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 87309. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations The licensee will ensure all toxic materials are stored in locked cabinets at all times. Plan of correction will be submitted by POC due date: 06/27/22.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/26/2022 03:41 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/26/2022 at 11:19 AM
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: CITADEL HOMES, INC.
FACILITY NUMBER: 198601701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above and identified the microwave oven was uncleaned and unsanitary. The violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 87303. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations The licensee will ensure the facility is maintained clean, safe and sanitary at all times. . Plan of correction will be submitted by POC due date: 07/10/22.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above identified toilet in bathroomo #2 in non-working condition. This violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 87303. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations The licensee will ensure all plumbing fixtures and toilets are in working condition at all times. Plan of correction will be submitted by POC due date: 07/10/22.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2022


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