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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607285
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:57:44 PM


Document Has Been Signed on 11/30/2023 02:57 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:LONGWORTH HOMEFACILITY NUMBER:
197607285
ADMINISTRATOR:LIBERTY VENTURAFACILITY TYPE:
740
ADDRESS:16439 LONGWORTH AVENUETELEPHONE:
7147208069
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:4CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Lilia OrdonezTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Lilia Ordonez and explained the purpose for todays visit. The facility phone number is 562 219 0158.

The facility consist of 5 bedrooms(1 staff room), 2 bathrooms, living room, dining room, kitchen, laundry area in the garage and an indoor/outdoor activity area.

The facility had all postings at the front entrance, bathrooms, and throughout the facility. A Pre screening area with PPE supplies was observed upon entry into the facility.

LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher on a wall next to the kitchen. The water temperature was tested and measured at 106.3-108.9 degrees F.

Administrators Certificate for Peter John E Ventura #600438740 has been renewed and it is pending/awaiting the certificate.

The following deficiency was cited in accordance to the California Code of regulations title 22, division 6, chapter 8. Appeal rights given.

A copy of this report was given during the exit interview.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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Document Has Been Signed on 11/30/2023 02:57 PM - It Cannot Be Edited

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: LONGWORTH HOME
FACILITY NUMBER: 197607285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by: LPA Wesley did a tour of the physical plant and saw wood pieces, and debris in the back yard.
Deficient Practice Statement
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Based onobservation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2023
Plan of Correction
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The licensee shall have the items removed by POC date 12/30/2023 and send a picture to LPA Wesley showing the items were removed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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