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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191803504
Report Date: 06/04/2024
Date Signed: 06/04/2024 01:15:05 PM

Document Has Been Signed on 06/04/2024 01:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MARISVILLE GUEST HOMEFACILITY NUMBER:
191803504
ADMINISTRATOR/
DIRECTOR:
LEE, UN JOONGFACILITY TYPE:
735
ADDRESS:911 NORTH MARIPOSA AVENUETELEPHONE:
(323) 662-5220
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY: 23CENSUS: 20DATE:
06/04/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:John Lee - Designated StaffTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit to follow up on deficiencies given on 5/23/24 during an annual visit. LPA met with John Lee and explained the reason for the reason.

On 5/23/24 LPA Flores conducted an unannounced annual visit at the facility and cited the following:
Type A - Section CCR - 80088(e)(1) Fixtures, Furniture, Equipment, and Supplies: On 5/3/24 water temperature tested at 122.1 in bathroom #1 (2nd floor). On 6/4/24 LPA Flores tested water temperature in the three bathrooms and tested between 109.3 - 111.2 degrees F., which is within the required 105-120 degrees F. Deficiency cleared as of 6/4/24.

Type B - Section - CCR - 85095.5(c) Infection Control Requirements: On 5/3/24 Infection Control Plan was not available for review. On 6/4/24 LPA Flores was provided a copy of Infection Control Plan and meets the requirements for new Title 22 Regulations. Deficiency cleared as of 6/4/24.

Type B - Section - CCR - 80088(b) Fixtures, Furniture, Equipment, and Supplies: On 5/3/24 screen in the screen door exiting to the balcony was ripped. On 6/4/24 LPA Flores observed the screen door was removed as it is not needed in the balcony. Deficiency cleared as of 6/4/24.

Evacuation chairs have been order and waiting for delivery. HIV/TB training was conducted on 6/3/24. Emergency Drill was conducted on 5/24/24.

Exit interview was conducted with John Lee and a copy of this report and clearance letters were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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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