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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600825
Report Date: 10/14/2022
Date Signed: 11/15/2022 09:19:26 AM

Document Has Been Signed on 11/15/2022 09:19 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DIANA'S HOMEFACILITY NUMBER:
191600825
ADMINISTRATOR:RENTERIA, DIANA LEEFACILITY TYPE:
735
ADDRESS:827 GIAN DRIVETELEPHONE:
(310) 533-5128
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 6CENSUS: DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:TIME COMPLETED:
11:50 AM
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On 10/14/2022, Licensing Program Analyst (LPA) Wendy Gibbs and Ernand Dabuet conducted an unannounced annual required visit using CARE Inspection Tool. LPA met with Administrator Eve Tighe and explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory developmentally disabled adults between the ages of 18 through 59.
Structure: Facility is two-story structure located in a residential neighborhood. It consists of the following: three (4) client rooms, two (2) client bathrooms, one (1) staff quarters including a bathroom, one (1) living area, one (1) dining area, one (1) computer area including a separate room for staff/storage, and kitchen.
Physical Plant Outside patio area including a shed for storage and a table with an umbrella for shade. There were no bodies of water. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility.

Bedrooms Bedroom 1, 2 and 3 have individual beds, one chairs and one to two dressers. Adequate lighting provided. Beds and bedding supplies were in good condition, storage for client personal belongings was observed.

Staff Room Has a bed and a bathroom

Bathroom Bathrooms 1 was observed to have a working toilet, wash bin and shower/tub, The water temperature measured 109.4 degrees F. Bathroom 2 was observed to have a working toilet, wash bin and shower/tub. Bathrooms were fully stocked with hand soap, paper towels and extra toiletries

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillow cases, hand towels, bath towels and wash cloths where observed stored in the hallway cupboard.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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 2
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: DIANA'S HOME
FACILITY NUMBER: 191600825
VISIT DATE: 10/14/2022
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Kitchen The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Water temperature measured 110.6 degrees F. Stove top burners were all in working condition. Additional refrigerator and freezer on grounds with additional food.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a land line, was checked by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on the wall between of the living room. Two fully charged fire extinguisher was found next to the kitchen as well as at the top of the stairs. First aid kit was inspected and contained all necessary items as well as the manual. Last fire drill was on 08/16/22 at 6pm.

LPA’s observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. There are two (2) fire extinguishers fully charge, one (1) in the kitchen and one (1) at the top of the stairs, smoke detectors and carbon monoxide were operable. A reviewed of Medication Records Administration (MAR) and observed to be maintained in order and accurate. All resident records were reviewed and contained all necessary paperwork. All staff records were reviewed and contained all necessary paperwork. Also reviewed staff and clients vaccination cards.

During the visit, LPA observed the facility 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.



No deficiencies were cited during this inspection visit.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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