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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802586
Report Date: 03/24/2023
Date Signed: 03/24/2023 02:49:46 PM

Document Has Been Signed on 03/24/2023 02:49 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:COLIMA HOMEFACILITY NUMBER:
197802586
ADMINISTRATOR:PENAFRANCIA ORBITAFACILITY TYPE:
735
ADDRESS:11039 COLIMA ROADTELEPHONE:
(562) 941-8264
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 6CENSUS: 3DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michelle Gozon-Puno TIME COMPLETED:
03:10 PM
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LPA's Angelica Rea and Erik Zaragoza made an unannounced visit to Colima Home. The purpose of today’s visit was to conduct the Required Inspection. On today’s visit LPA's met with staff, Administrator, Michelle Gozon-Puno. The home has 3 consumers, all are ambulatory and none has a restricted health care condition. The facility conducted a fire drill on 3/2/23.

LPA Rea checked Client & Staff files, medications, staff fingerprint clearances, staff 1st aid certificates, consumer IPPs and inspected the home for hazards. During this visit, LPA inspected consumer bedrooms, 2 bathroom, living room, dining room and kitchen, and laundry area. The consumer bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Bedrooms had plenty of dresser and closet space observed. Walls and floors were in good condition. Hallways were clean, clear, and free of debris. Toilets and water facets worked properly. Water temperature measured between 105 degrees F and 120 degrees F, in 2 bathrooms, and in the kitchen, as required. The fire extinguisher is fully charged and meets regulations.

Perishable food supply was checked and adequately stocked at time of visit. Smoke detectors were working properly, chemical compounds and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and in order. Outside grounds were toured and no bodies of water were observed.

No deficiencies cited. Exit Interview, and copy of report provided to Ms. Puno.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023
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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