198603249-4-4-2023-11-AS-LVIS-CP5SA9-20230217124157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603249
Report Date: 02/17/2023
Date Signed: 04/04/2023 02:19:22 PM

Document Has Been Signed on 04/04/2023 02:19 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:	CERVATO COTTAGE		FACILITY NUMBER:	198603249
ADMINISTRATOR:	UMANA, JOSE		FACILITY TYPE:	740
ADDRESS:	4622 E. CERVATO STREET		TELEPHONE:	(818) 606-6136
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY: 6		CENSUS: 5	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Jose Umana		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/17/23, Licensing Program Analysts (LPA) Lizeth Villegas and Licensing Program Manager (LPM) Janae Hammond conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA and LPM met by Bernadett Coloma, Administrator Jose Umana arrived shortly after to assist with the visit. LPA and LPM explained the purpose of today’s visit. The facility is licensed to operate for 6 ambulatory residents of which 6 can be non-ambulatory, ages 60 and over and is approved hospice waiver for 6 residents. The facility is a single story 6 bedrooms, 2 common restrooms, 1 private restrooms, laundry room, dining area, kitchen, pantry, linen closet, 1 staff office area and a designated outdoor shaded area. The facility water temperatures measured between 105- and 109-degrees F. The facility has a working landline telephone. LPA and LPM toured the physical plant. There were no bodies of water or obstructions on the premises. Resident rooms were inspected, beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked during the visit. All bathrooms were found to be within Title 22 regulations and were clean and operational. LPA and LPM observed the facility to be sanitary and appropriately furnished at the time of visit. All storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. LPA and LPM reviewed Medication Administration Records (MAR) revealed to be accurate and maintained in order. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate, the last fire drill and

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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: CERVATO COTTAGE	FACILITY NUMBER: 198603249
	VISIT DATE: 02/17/2023

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disaster drill were on 12/02/2022.

During the visit, LPA and LPM observed the facility's infection control practices. LPA and LPM observed there were no screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA and LPM observed staff wearing face coverings, LPA and LPM observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Most mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan. The facility has submitted an Infection Control Plan to the regional office.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

There are no deficiencies cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Jose Umana.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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