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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803285
Report Date: 07/28/2022
Date Signed: 07/28/2022 10:23:56 AM

Document Has Been Signed on 07/28/2022 10:23 AM - 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:CARFAX HOMEFACILITY NUMBER:
197803285
ADMINISTRATOR:LUZ H. RASCOFACILITY TYPE:
735
ADDRESS:4313 CARFAX AVENUETELEPHONE:
(562) 627-9612
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 2DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Luz Rasco - Administrator TIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Luz Rasco and explained the reason for the visit. The facility is licensed to serve one non-ambulatory and three ambulatory clients ages 18-59. Facility currently has 1 non-ambulatory and 1 ambulatory client serviced by Harbor Regional Center.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the living room, dining room, kitchen, 4 client bedrooms, 2 client bathrooms, laundry area, front yard, backyard, and detached garage/office room.

LPA Mora conducted the tour with Luz Rasco and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked in a cabinet above the washer and dryer and also under the kitchen sink. The First Aid kit is kept above the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet near the kitchen. Client and staff files are kept in the garage/office room. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 113.3 degrees F and 1116.7 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. There is one carbon monoxide located in the kitchen and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CARFAX HOME
FACILITY NUMBER: 197803285
VISIT DATE: 07/28/2022
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LPA reviewed medication for 1 client and observed that medications are documented properly and given as prescribed. One of the clients is on vacation with the family since 07/23/2022 and the family took the medications. LPA reviewed files for all 2 clients and 2 staff. LPA observed administrator certificate for Luz Rasco - 6010894735 with an expiration date of 02/18/2024.

Facility has 30 days supplies of Personal Protective Equipment in the backyard. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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