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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607854
Report Date: 03/18/2024
Date Signed: 03/18/2024 11:45:34 AM


Document Has Been Signed on 03/18/2024 11:45 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:IMPERIAL CAREFACILITY NUMBER:
197607854
ADMINISTRATOR:IRENE B. IMPERIALFACILITY TYPE:
740
ADDRESS:18423 NORAN AVENUETELEPHONE:
(562) 402-4444
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 5DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Irene Imperial TIME COMPLETED:
12:05 PM
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On 3/18/24 at 8:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Imperial Care. Upon arrival LPA was greeted by Direct Support Professional (DSP) Joy Bautista who contacted the Administrator. The Administrator Irene Imperial arrived at 8:50 a.m., to assist with today's visit. The licensee prefers to serve age 60 and older. Five (5) Non ambulatory and one (1) bedridden. Hospice wavier approved for one (1) resident only. There were (5) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 3/11/2024. The Administrator Certificate expires on 10/12/2024 #7011263740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (5) residents files, medications, and medication administration records for (5) residents.

This home contains 3 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (5) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 114.6*F-115.3*F The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (1) fire extinguishers located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured in a kitchen cabinet. Cleaning agents and toxins were locked underneath kitchen sink. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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 2


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: IMPERIAL CARE
FACILITY NUMBER: 197607854
VISIT DATE: 03/18/2024
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for resident use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, PPE supplies and toxins and cleaning agents.

The dining room contained playing cards, board games and activity supplies available to the residents. In addition, a non-working fireplace contained a covered screen so that it was inaccessible to the residents. The dining room also contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

Exit interview conducted with Irene Imperial, Administrator, a copy of this report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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