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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802583
Report Date: 05/28/2024
Date Signed: 05/28/2024 01:35:06 PM

Document Has Been Signed on 05/28/2024 01:35 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SANTOS HOMEFACILITY NUMBER:
197802583
ADMINISTRATOR/
DIRECTOR:		LOURDES SANTOSFACILITY TYPE:
735
ADDRESS:11703 JAMES STREETTELEPHONE:
(562) 924-5149
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 4DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:Administrator Jay SamilinTIME VISIT/
INSPECTION COMPLETED:
01:49 PM
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On 5/28/24 at 8:29 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Santos Home. Upon arrival LPA was greeted by Assistant Administrator Ma-Rhona Amado who contacted the Administrator, Jay Samilin. LPA Baptiste explained the reason for the visit to both the Administrator and Assistant Administrator. This home is licensed to serve (4) Developmentally Disabled Ambulatory Adults, (1) non-Ambulatory and (3) Ambulatory Adults ages 18 through 59. The is a level 4G home and the vendor is Harbor Regional Center. There were (4) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 5/23/2024. The Administrator Certificate expires on 6/02/2024 #6017360735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (4) client files, medications, medication administration records for (4) clients and P&I. LPA interviewed three (3) staff and due to all clients limited communication LPA could not proceed with client interviews.

This home contains 4 bedrooms, 1 staff bedroom, 2 bathrooms, living room/ office space, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. Assistant Administrator stated client punched a hole in the wall. The two bathrooms contain a working toilet, basin, and water faucet. One (1) bathroom contained a walk-in shower with grab bar, shower chair, and bathmat. The temperature measured at 118.5*F-117.5*F. The smoke detectors were interconnected, tested, and observed to be working properly. The carbon dioxide is located in the hallway tested and observed to be working properly.

(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANTOS HOME
FACILITY NUMBER: 197802583
VISIT DATE: 05/28/2024
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There were (1) fire extinguisher located in kitchen and dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked underneath kitchen sink with cleaning agents and toxins. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines.

The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, food and storage.

The office space contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

Exit interview conducted with Jay Samilin, Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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