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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802585
Report Date: 04/18/2023
Date Signed: 04/18/2023 05:16:07 PM

Document Has Been Signed on 04/18/2023 05:16 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:EL ESPEJO HOMEFACILITY NUMBER:
197802585
ADMINISTRATOR:MARIA MADRIGALFACILITY TYPE:
735
ADDRESS:13823 EL ESPEJO ROADTELEPHONE:
(562) 941-5674
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 6DATE:
04/18/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Michelle Gozon-PunoTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos conducted an annual continuation visit using the Inspection tool. LPA met with Administrator Michelle Gozon-Puno and the purpose of the visit was discussed.

Initial visit was conducted on 4/17/23 and the Inspection tool was used but not completed. LPA toured the physical plant and interviewed Client #1-#6 and Staff #1-#4.

On todays visit. LPA completed the Inspection tool, reviewed files for clients #1-#6 and medications for clients #1-#5. Client #6 does not take medications. LPA also reviewed staff files for Staff #1-5. Inspection tool was completed. deficiencies are being cited under the California Code of Regulations Title 22 Division 6. An exit interview was conducted and appeal rights were given and discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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 2
Document Has Been Signed on 04/18/2023 05:16 PM - It Cannot Be Edited


Created By: Jose Villalobos On 04/18/2023 at 10:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EL ESPEJO HOME
FACILITY NUMBER: 197802585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above as 1 knife was left unattended and accessible in the kitchen sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
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Deficiency cleared at the time of the intial visit on 4/17/23. LPA observed staff remove knife from sink and lock in a drawer with other sharps.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
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