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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608094
Report Date: 11/09/2024
Date Signed: 11/09/2024 10:31:17 AM

Document Has Been Signed on 11/09/2024 10:31 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NARRA TREE INC/IBEX HOMEFACILITY NUMBER:
197608094
ADMINISTRATOR/
DIRECTOR:
MA. TERESA SANTOSFACILITY TYPE:
740
ADDRESS:18918 IBEX AVENUETELEPHONE:
(562) 860-1599
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Hazel Tuason DSPTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Hazel Tuason at approximately 8:30 AM and explained reason for visit. House Manager Ma Dalisay Lazo arrived shortly.

Facility is licensed to serve (6) developmentally disabled adults, ages 18-59. Four can be bedridden and two non-ambulatory. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, kitchen, 4 client bedrooms, 2 bathrooms, laundry area, front yard, backyard, and attached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the dining room and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in laundry room. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

Tony VasalloTELEPHONE: (323) 981-3977
Christian GutierrezTELEPHONE: 323-981-3984
DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NARRA TREE INC/IBEX HOME
FACILITY NUMBER: 197608094
VISIT DATE: 11/09/2024
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in October of 2024. Infectious control plan was reviewed. One (1) staff and (1) client was interviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

No deficiency was observed during today’s visit. Exit interview was conducted with House Manager and a copy of report was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
LIC809 (FAS) - (06/04)
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