<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221043
Report Date: 05/16/2022
Date Signed: 05/16/2022 02:29:48 PM

Document Has Been Signed on 05/16/2022 02:29 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOMES FOR LIFE FOUNDATION WILSON HOUSEFACILITY NUMBER:
191221043
ADMINISTRATOR:LIESS, CAROLFACILITY TYPE:
735
ADDRESS:54 N. WILSON AVETELEPHONE:
(626) 568-3657
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 8CENSUS: 8DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Lerisa Cantos - House ManagerTIME COMPLETED:
02:30 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
Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food, and medication review. LPA met with Lerisa Cantos House Manager and explained the reason for the visit. Program Manager Katrin Silvestro arrived 20 minutes later.

Facility is licensed to serve 8 ambulatory clients between the ages of 18-59 years old. Facility is a two story house with 4 client bedrooms, 2 clients bathroom, 1 live-in staff bedroom, 1 staff bathroom, living room, dining room, kitchen, an office, detached garage, front and back porch with laundry room area, and a shaded outdoor sitting area. No large bodies of water were observed.

LPA Flores conducted the tour with Lerisa Cantos House Manager and observed the following:
Smoke/Carbon Monoxide detectors were observed, tested, and are in working condition. Fire extinguisher was observed. Sufficient food for at least 2 days worth of perishables, and 7 days worth of non-perisables in the kitchen. Sharps were locked in kitchen drawer, and cleaning supplies under kitchen's sink. Bathroom #1(B1) and #2(B2) were observed to have hand washing signs, soap, paper towels, grab bars, and skid mats (as they have some clients over the age of 60), water temperature was tested as follow: B1 tested at 112.3 degrees F., and B2 tested at 109.5 degrees F., which is within the required 105-120 degrees F. All bedrooms have sufficient lighting, all required furniture, and bedding supplies. Signs were observed throughout the facility.
LPA reviewed medication and files for 4 clients and files for 3 staff. Staff have been Fit Tested for N95 masks.
Administrator certificate was observed for Carol M. Liess #6025209735 expiration date: 2/25/23

No deficiencies were noted during this visit under Title 22 Regulations.


Exit interview was conducted with Lerisa Cantos House Manager and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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 1