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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802586
Report Date: 02/14/2025
Date Signed: 02/14/2025 03:36:25 PM

Document Has Been Signed on 02/14/2025 03:36 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COLIMA HOMEFACILITY NUMBER:
197802586
ADMINISTRATOR/
DIRECTOR:		PENAFRANCIA ORBITAFACILITY TYPE:
735
ADDRESS:11039 COLIMA ROADTELEPHONE:
(562) 941-8264
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 6CENSUS: 2DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Annie Basa - House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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License Program Analysts (LPAs) Luis De Leon, Mayra Cota, and Blanca Gonzalez along with Fernando Fierros (LPM) conducted an unannounced annual required visit to Colima Home. LPAs met with house manager Annie Basa, assistant administrator Cristina Obstaculo joined during the facility tour. Administrator Michelle Puno joined later during the visit. The purpose of today’s visit was explained to facility personnel met during this visit. Facility is licensed to serve developmentally disabled adults ages 18 thru 59 years old, of which, four (4) may be ambulatory and two (2) non-ambulatory, for a total of 6 clients.

The LPAs use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows:

The following Client records were reviewed: Client Admission Agreements, Client files, and Consumer IPPs.

The physical plant was toured, and the following was observed: three (3) client bedrooms and one (1) staff bedroom, Two (2) bathrooms, Living room and Shaded Outdoor patio/Terrace, Kitchen and Dining room, attached Garage, and Front and Back yard.

Observations during facility tour:



· Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPAs observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for clients.
· Wall and floors are in good repair. Hallways were clean and free of obstructions.
· Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable.
· Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean.

Report continues on LIC-809C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COLIMA HOME
FACILITY NUMBER: 197802586
VISIT DATE: 02/14/2025
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· The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees.
· Sharps are locked in kitchen and inaccessible to clients. Also, chemicals and cleaning supplies are locked and secured inaccessible to clients.
· Medications centrally stored and inaccessible to clients.
· Smoke and carbon monoxide detectors were observed and are interconnected throughout the facility. One (1) fire extinguisher was observed and was fully charged with last inspection on September 2024.
· Front and back yards are free of hazards and there were no bodies of water present at facility. Shaded area was available to clients.

Administrator was advised to update facility sketch (LIC 999)and provide a copy to department by Tuesdaym 02/18/25.

Due to time constraints staff files will be reviewed at a later date.

No deficiencies were cited per California Code of Regulations, Title 22, Division 6. An exit interview was conducted, and a copy of the report was provided to Michelle Puno.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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