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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608094
Report Date: 12/04/2023
Date Signed: 12/04/2023 04:19:31 PM


Document Has Been Signed on 12/04/2023 04:19 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:NARRA TREE INC/IBEX HOMEFACILITY NUMBER:
197608094
ADMINISTRATOR:MA. TERESA SANTOSFACILITY TYPE:
740
ADDRESS:18918 IBEX AVENUETELEPHONE:
(562) 860-1599
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:6CENSUS: 4DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Administrator Teresa SantosTIME COMPLETED:
04:34 PM
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On 12/4/23 at 12:52 p.m., Licensing Program Analysts (LPAs) Jewel Baptiste and Sanjay Vaid conducted an unannounced Annual/Required inspection to Narra Tree Ibex Home. Upon arrival LPA was greeted by Direct Support Professional (DSP) Joan Concepcion who contacted the Administrator, Teresa Santos, at 9:02 a.m. LPAs explained the reason for the visit. This home is licensed to serve (4) Bedridden and (2) non-Ambulatory ages 60 and above. The facility has 24/7 awake staff. The facility prefers to serve developmentally disable residents. There were (4) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 11/23/2023. The Administrator Certificate expires on 4/27/2025 #6025870740. The facility is vendored through Harbor Regional Center. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (2) staff files, (4) client files, medications, and medication administration records for (4) clients and P&I.

This home contains 4 bedrooms, 2 bathrooms, living room, laundry room, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) client 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 107.6*F-109.5*F. The smoke detectors were battery operated and individually tested and was working properly. The carbon monoxide detector was in living room and observe to be functioning properly. There were (1) fire extinguishers located in the laundry room 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. The knives secured and locked in kitchen cabinet. The cleaning agents and toxins was 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.
(Report continued on LIC809C.)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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: NARRA TREE INC/IBEX HOME
FACILITY NUMBER: 197608094
VISIT DATE: 12/04/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained with exercise machines and a shaded seating area accessible for client use. The garage contained cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The dining room contained playing cards, board games, music supplies, and activity supplies available to the clients.

The office 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 Teresa Santos, 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: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC809 (FAS) - (06/04)
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