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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802587
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:22:32 PM

Document Has Been Signed on 03/19/2024 03:22 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:CULLEN HOMEFACILITY NUMBER:
197802587
ADMINISTRATOR:PENAFRANCIA ORBITAFACILITY TYPE:
735
ADDRESS:14397 CULLEN STREETTELEPHONE:
(562) 696-9694
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 6CENSUS: 4DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Michelle Gozon-TIME COMPLETED:
03:15 PM
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LPA Angelica Rea made an unannounced visit to Cullen Home. The purpose of today’s visit was to conduct the Required Inspection. On today’s visit LPA met with staff, Minerva Cobilla and Administrator, Michelle Gozon-Puno. The home has 4 consumers, all are ambulatory and none has a restricted health care condition. The facility conducted a fire drill on 3/12/24.

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, 1 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 111.3 degrees F in the kitchen, and 111.3 degrees F in the bathroom. 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.

There were no deficiencies found on today's visit. Exit interview conducted and copy of report was provided to Ms. Gozon-Puno.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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