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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800817
Report Date: 02/11/2023
Date Signed: 02/11/2023 11:49:34 AM

Document Has Been Signed on 02/11/2023 11:49 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: 5DATE:
02/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Samuel SemeneaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced required annual inspection. LPA met with Staff, who allowed entry DSP worker Georgeta "GiGi" Georgescu and explained the purpose of the visit. Shortly after Administrator Samuel Semenea arrived at the facility.

During today's visit LPA conducted a tour of the physical plant with Samuel. The facility has 6 private rooms, 2 bathrooms, 2 living rooms, kitchen with dining area, and detached garage. Laundry area, Emergency Supplies, Extra Food Goods, extra refrigerator and freezer are located in the garage inaccessible to clients. LPA observed front patio with shaded area and a backyard, there are no large bodies of water at the facility. LPA observed the following:
  • 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.
  • 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 in storage closet.

LPA reviewed 5 clients medications and medications record documentation, and did not observe any
deficiencies in this area. LPA used the Infection Control Domain with Samuel. Facility conducts temperature checks upon entry for staff, clients and visitors. Coronavirus (COVID-19) signage are posted in several areas of the facility. Hand washing signs are posted in the bathrooms. Sufficient PPE for over 90 days. Administrator Samuel Semenea Administrator Certificate Expires: 9/14/23. LPA Calderon assisted Samuel how to access Guardian Website. Client's associated with South Central Los Angles Regional Center. Last Fire Drill was conducted on 12/19/22, Fire Drill conducted quarterly.

LPA did not observe any deficiencies during the visit today. Exit interview was conducted and a copy of this report was provided Administrator Samuel Semenea.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2023
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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