197609024-12-26-2023-31-AS-LNCA-CYVVQH-20231226153821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609024
Report Date: 12/26/2023
Date Signed: 12/26/2023 03:38:29 PM

Document Has Been Signed on 12/26/2023 03:38 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CENTRO		FACILITY NUMBER:	197609024
ADMINISTRATOR:	JUANA I. BUSBY		FACILITY TYPE:	735
ADDRESS:	2315 N SANTA ANITA AVE		TELEPHONE:	(626) 529-5940
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY: 6		CENSUS: 6	DATE:	12/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Ivette Busby- Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff Bridgitte Djotang at 12:15 pm and was advised for the purposed of the visit, around 12:40 pm the administrator Juana Ivett Busby arrived. At 12:45 pm, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational and their carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen and living room with the charge date is 12/3/2023. During the visit the facility is at 72 degrees Fahrenheit. The facility is fire cleared for six (06) ambulatory. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Food storage and preparation areas are clean and inaccessible to pests. Knives were stored in a locked cabinet in the kitchen. Properly labeled medications were locked in the kitchen cabinets. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away. LPA discussed special diets for diabetic resident. Bedrooms: There were three (3) bedrooms designated for residents' use. Three (3) of the bedrooms are shared and is in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #1, room #2 and #3 are properly furnished and occupied by shared residents. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Bathroom #1 hot water temperature was measured at 119.9 degrees Fahrenheit and bathroom #2 measured 119.1 degrees Fahrenheit. Bathroom #1 is located in between bedroom #1 and bedroom #2. Bathroom #2 is located inside bedroom #3. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CENTRO	FACILITY NUMBER: 197609024
	VISIT DATE: 12/26/2023

NARRATIVE

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Cleaning supplies are being stored in a locked cabinet in the kitchen beside the laundry. Towels and washcloths are not shared. There was enough clean linen available in the cabinets in the hallway.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Furniture in common area was observed to be in good repair. Fire place is closed, block-off, and non-operational in the living room. No obstructions and or tripping hazards throughout the facility. Residents dining table fits enough for six (6). Office is located in the common area of the living room.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the laundry room in the kitchen that are kept secured. The facility does not have a swimming pool or body of water. The garage is detached and is used for storage and for residents and food storage. There are no issues with Fire Clearance.

Infection control: LPA reviewed facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Laundry service: There is enough linen available to change weekly or more if need.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for expired or missing certificates and clearances: LPAs conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CENTRO	FACILITY NUMBER: 197609024
	VISIT DATE: 12/26/2023

NARRATIVE

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Medications: Medication and Medication Records (MMR) were review for proper documentation. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

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