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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800817
Report Date: 02/02/2022
Date Signed: 02/02/2022 11:47:09 AM

Document Has Been Signed on 02/02/2022 11:47 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:HOME OF (TLC)FACILITY NUMBER:
197800817
ADMINISTRATOR:SEMENEA, SAMUELFACILITY TYPE:
735
ADDRESS:12159 JULIUS AVE.TELEPHONE:
(562) 928-7009
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 6CENSUS: 6DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Samuel Semenea, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced required annual inspection with the focus of the Infection Control domain. LPA met with Staff, who allowed entry, and explained the purpose of the visit. The Administrator, Samuel Semenea arrived shortly thereafter to assist with the inspection. The facility is licensed for 6 ambulatory developmentally disabled adults between ages 18-59. There are currently 6 clients residing at the home.

LPA Chan observed/inspected the following:
* The facility has 6 private rooms, 2 bathrooms, 2 living rooms, ktichen with dining area, and detached garage. Laundry area is located in the garage. There are no bodies of water at the property.
* Facility conducts temperature checks upon entry for staff and visitors.
* Coronavirus (COVID-19) signage are posted in several areas of the facility. Hand washing signs are posted in the bathrooms and kitchen.
* There are sufficient supplies of 2 day perishable and a week of nonperishable items observed.
* There are operable smoke detectors and a carbon monoxide detector at the facility.
* Extra supplies of PPEs and soaps are stored and locked in the storage room.
* Knives and disinfectants/cleaning products are stored and locked in the space behind the entry door.
* The hot water temperature was measured between the required range of 105-120 degrees Fahrenheit.
* Medications are centrally stored and locked. LPA reviewed 4 out of the 6 clients, who are taking medications, and did not observe any deficiencies in this area.
* Per Administrator, staff are cleaning daily and on every shift.

LPA provided technical assistance for the following item:
N95 respirators Fit Testing

LPA did not observe any discrepancies during the visit today. Exit interview was conducted and a copy of this report along with appeal rights were given to Mr. Semenea.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
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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