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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802585
Report Date: 04/17/2023
Date Signed: 04/17/2023 11:31:33 PM


Document Has Been Signed on 04/17/2023 11:31 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:
04/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Cristina ObstaculaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos and Associate Governmental Program Analyst (AGPA) Michael Moriel conducted an annual inspection using the Inspection tool. LPA and AGPA met with Administrator Cristina Obstacula and the purpose of the visit was discussed.

As a part of the inspection, LPA Villalobos and AGPA Moriel used the inspection tool. There are currently (6) clients , all ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. Facility is a one story family home with four (4) bedrooms, (2) bedrooms are for 2 clients each and (1) bedroom is for staff. There are (2) full bathrooms, living room, kitchen, central air and heating, dining area, laundry room, a shaded area located in the backyard. a detached car garage inaccessible to clients. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms are equipped with beds each, a dresser, lamp, chair, overhead lightning for each client. Bathroom has a working toilet, wash basin, one has a bathtub and the other has a shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored in each client's bedrooms were observed. Fire alarms were observed and operational. Required postings observed.

Due to time constraints, LPA could not complete file and medications reviews. LPA to continue annual visit at a later date to complete inspection tool domains.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
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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