<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801985
Report Date: 03/30/2022
Date Signed: 04/27/2022 11:56:37 AM

Document Has Been Signed on 04/27/2022 11:56 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:LOVE N CARE GUEST HOMEFACILITY NUMBER:
197801985
ADMINISTRATOR:BRILLANTES, HARRYFACILITY TYPE:
735
ADDRESS:11866 E. 162ND. ST.TELEPHONE:
(562) 404-7601
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 8CENSUS: 6DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 AM
MET WITH:Luz BrillantesTIME COMPLETED:
03:00 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) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Luz Brillantes and Elizabeth Mungcal and explained the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 562 404 7601.

The facility consist of four resident bedrooms, one staff bedroom, three bathrooms(one located in staff area), a living room, dining room, kitchen, a patio with umbrella/table/chairs, backyard with storage sheds, and an attached garage(office area, storage, additional food).

During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, and throughout the facility. A Pre screening area with PPE supplies near the facility entrance.

LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the kitchen/dining room area. The water temperature was tested and measured 116.9 degrees F.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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 1