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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607612
Report Date: 11/27/2023
Date Signed: 11/27/2023 11:56:38 AM


Document Has Been Signed on 11/27/2023 11:56 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MONACO CREST GUEST HOMEFACILITY NUMBER:
197607612
ADMINISTRATOR:CARINA DEMMANFACILITY TYPE:
740
ADDRESS:15225 METROPOL DRIVETELEPHONE:
(562) 693-9470
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:6CENSUS: 6DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Carina Demman, AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Carina Demman. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. Infection Control Plan observed.

Operational Requirements:
  • A current Plan of Operation observed.
  • A fire clearance for 6 residents of which (6) may be non ambulatory
  • Hospice care waiver approved for one (1) resident.

Physical Plant/Environment Safety:
  • Facility is a single story home consisting of 7 bedrooms (5 resident rooms & 2 staff rooms), 3 bathrooms, living room, family room, dining room, kitchen, laundry room, backyard with shaded patio furniture, and an attached garage
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:
  • A total of (4) staff members provide supervision to the residents.
  • Sufficient staff observed during visit

Continued on LIC 809-C
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MONACO CREST GUEST HOME
FACILITY NUMBER: 197607612
VISIT DATE: 11/27/2023
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Personnel Records - Staff Training:
  • Administrator on file is current.
  • Staff have criminal background clearance and training.
  • Four (4) staff files were reviewed. Required training observed

Resident Records - Incident Reports:
  • A total of Six (6) resident files were reviewed.
  • Required postings observed
Resident Rights - Information
  • Required postings observed
Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • Activities supply observed

Food Service:
  • Sanitation practices and kitchen cleanliness was observed.
  • Kitchen has utensils for clients to use and to store their meals

Incident Medical and Dental:
  • Emergency transportation available
  • First Aid Kid observed
  • (6) of (6) Resident medications reviewed

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.

Residents with Special Health Needs:
  • Needs and Services Plan and Appraisals are on file.
  • Currently (0) residents receiving hospice services.
  • Orders for bed rails on file

Inspection Tool was completed and no deficiencies are being cited on todays visit.
Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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