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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803785
Report Date: 12/10/2022
Date Signed: 12/10/2022 11:08:24 AM

Document Has Been Signed on 12/10/2022 11:08 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MELROSE HOMEFACILITY NUMBER:
197803785
ADMINISTRATOR:DELIA COLLANTESFACILITY TYPE:
735
ADDRESS:4174 CENTER ST.TELEPHONE:
(626) 813-7525
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 6CENSUS: 5DATE:
12/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Administrator Delia B CollantezTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Caregiver Tony Vergara and explained the reason for the visit. Administrator Delia Collantes arrived shortly thereafter. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected. The facility is licensed to serve up to (2) two non-ambulatory ambulatory and (4) ambulatory clients ages 18 - 59. The facility currently has 1 client over the age of 60 years old and 4 under the age of 59 years old. The Administrator’s Certificate is current with an expiration date of 06/09/23. Fire drill was last conducted 6-18-22.

LPA and Caregiver Vegara toured the home. LPA observed a fenced in yard and enclosed backyard. The facility consists of three (3) client bedrooms, one (1) client bathroom, one (1) staff bedroom, one (1) staff bathroom, kitchen, living room, dining room, and detached garage. Water temperature in kitchen was measured at 108.8 degrees F which is within in the required 105-120 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to clients. Fire extinguisher kept in the kitchen area is fully charged and was last inspected 6-18-22. Cleaning supplies and toxins are locked under the sink and are inaccessible to clients. Water temperature in client bathroom was measured at 105.9 degrees F which is within the required degrees 105-120 degrees F. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen, and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector located in the hallway of the home. Five (5) out of the five (5) client medications were reviewed. Medications are centrally stored in a cabinet located in the dining room. Medications are documented properly and given as prescribed. Staff and Client files were not reviewed during today's visit.



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: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2022
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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