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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593155
Report Date: 03/28/2024
Date Signed: 03/28/2024 11:41:44 AM

Document Has Been Signed on 03/28/2024 11:41 AM - 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:LISA MARIE GUEST HOMEFACILITY NUMBER:
191593155
ADMINISTRATOR:OTERO, IMELDAFACILITY TYPE:
735
ADDRESS:3451 SANTA ANA ST.TELEPHONE:
(323) 587-8726
CITY:HUNTINGTON PARKSTATE: CAZIP CODE:
90255
CAPACITY: 6CENSUS: 5DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Bridgette WilinskiTIME COMPLETED:
12:00 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
Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Bridgette Wilinski and explained the reason for the visit. The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Administrator Bridgette Wilinski today 03/28/2024 at 9:25 AM and the following was observed:
Facility contains 6 Client Bedrooms and 2 Client Bathrooms, dining room, living room, TV room, and activity room.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.
Interviews were conducted with 3 clients and 1 staff (only staff on duty from 8 to 6). 6 client files and 1 staff file were reviewed
All staff were cleared and associated.
Medication was administered per physician's directions.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Staff responsible for providing care and supervision received training in First Aid.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Hot water temperature measured between 105F. and 120 F. meeting Title 22 Regulations.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
No deficiencies.
Exit interview conducted and copy provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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