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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601334
Report Date: 08/08/2023
Date Signed: 08/08/2023 03:11:24 PM


Document Has Been Signed on 08/08/2023 03:11 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:AYRES RESIDENTIAL CARE HOMEFACILITY NUMBER:
197601334
ADMINISTRATOR:GABAI, MICHAELFACILITY TYPE:
740
ADDRESS:10940 AYRES AVE.TELEPHONE:
(310) 475-4727
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:6CENSUS: 5DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Rosalie NavalTIME COMPLETED:
03:20 PM
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On 08/8/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Caregiver, Emalita Castaneda and explained the purpose of today’s visit. Administrator Rosalie Naval arrived later to assist with the annual. The facility is licensed to operate for six (6) residents of which six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for three (3) hospice. Todays census is 5.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms with one, (1) staff room, living area, den/dining area, kitchen and outside shaded patio area.

LPA Shirley and Rosalie Naval toured the physical plant. There are no bodies of water or firearms on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens and comforters were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 114.6. The fire extinguisher was serviced and operable.

A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. The smoke detectors and carbon Monoxide were operable.

Con'd 809C
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
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: AYRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 197601334
VISIT DATE: 08/08/2023
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LPA also observed that the facility has a 30-day supply of Personal Protective Equipment (PPE). And all mandated posters were posted.

There were no deficiencies observed during today’s visit. Exit interview held and a copy of the report was provided to the Administrator Rosalie Naval.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC809 (FAS) - (06/04)
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