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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604374
Report Date: 09/07/2022
Date Signed: 09/07/2022 02:54:29 PM


Document Has Been Signed on 09/07/2022 02:54 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 DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:AYRES RESIDENTIAL CARE HOMEFACILITY NUMBER:
197604374
ADMINISTRATOR:ANTANINA REMEIKIENEFACILITY TYPE:
740
ADDRESS:10862 WELLWORTH AVETELEPHONE:
(310) 475-6484
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY:6CENSUS: 5DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Antanina Remeikiene TIME COMPLETED:
03:00 PM
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On 09/07/2022 at 1:30pm, Licensing Program Analyst (LPA) Agard conducted an unannounced required annual visit with a primary focus on Infectious Control measures using the new CARE inspection tool. Upon arrival at the facility, LPA Agard conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) residents of which all may be non-ambulatory, one bedridden and/or have dementia. Facility is approved for 3 hospice waivers. Currently, there are five (5) residents present during today’s visit.

LPA met with Caregiver, Antanina Remeikiene and both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station in the facility with visitor’s log. The facility’s designated visitation area is in the front room of the facility. The staff was observed with a face covering. LPA observed required covid postings throughout the facility.

All rooms (6) were inspected. All rooms are single occupancy. Bed linen were sufficient in amount, mattresses were observed in good condition, adequate lighting was provided, storage for client personal belongings was observed.

Furniture in the living room observed to be in good condition. There are no weapons on the premises. Residents bathrooms were checked, toilets and water faucets worked properly. The water temperature measured within range. A comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a supply of perishable and a 7-day of non-perishable food. Cleaning supplies were observed locked. Centrally stored medications were observed stored in their originally received containers and observed locked and inaccessible to residents in care. Two fire extinguishers were observed fully charged. One in the kitchen and one in the hallway.

cont. on 809

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AYRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 197604374
VISIT DATE: 09/07/2022
NARRATIVE
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Outside grounds were toured, no bodies of water were observed. Walkways around the home were generally clear of hazards. Common areas were observed clean; All doorways were free of obstruction.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AYRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 197604374
VISIT DATE: 09/07/2022
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Outside grounds were toured, no bodies of water were observed. Walkways around the home were generally clear of hazards. Common areas were observed clean; All doorways were free of obstruction.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3