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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201550
Report Date: 08/20/2022
Date Signed: 08/20/2022 01:01:49 PM

Document Has Been Signed on 08/20/2022 01:01 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EMILY'S HOMEFACILITY NUMBER:
198201550
ADMINISTRATOR:EMILY'S MARQUEZFACILITY TYPE:
735
ADDRESS:359 E. 169TH STREETTELEPHONE:
(310) 329-6555
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 6DATE:
08/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rosalia Entena De La Cruz/Ian Melqui AndresTIME COMPLETED:
01:15 PM
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On 08/20/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to Emily’s Home. The purpose of today’s visit was to conduct the Required Annual inspection, with an emphasis on infection control. LPA was greeted by Rosalia Delacruz/DSP and Ian Andres (staff) and the purpose of today’s visit was explained. Currently, the home has (6) ambulatory clients and (0) non-ambulatory client. The facility is housed with South Central Los Angeles Regional Center clients with ages of 18-59.

LPA along with Rosalia Delacruz/DSP toured the entire facility inside and the outside grounds. This home consists of (3) client bedrooms (1) client bathroom. There’s (1) bedroom for a live-in staff with a bathroom. A living room, kitchen, dining area, activity room and patio. During the inspection LPA observed the following client rooms: mattresses and box springs in working condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. LPA observed fully stocked bedding and towel in closets. All bathroom fixtures are clean and working properly. LPA observed sufficient toiletries are accessible to clients. Water temperature properly measured at 106.8 degrees F.

There were adequate perishable and non-perishable food supplies. The kitchen cabinets and pantry were adequately stocked. LPA tested facility Carbon Monoxide and Smoke Detectors and are working properly. The facility has (1) Fire Extinguisher fully charged in kitchen area last inspected on 04/15/22. All cleaning solutions and toxins were in locked cabinets. Medications are centrally stored in metal cabinet locked in kitchen area and inaccessible to clients. Facility first aid kit and manual was checked and in compliance. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. As a part of the inspection, LPA also reviewed one client record, one staff record, and client P & I record, and medications were checked and all were in compliance.

Evaluation Report continues LIC 809C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: EMILY'S HOME
FACILITY NUMBER: 198201550
VISIT DATE: 08/20/2022
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During the visit, LPA observed the following to be complying: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD

No deficiencies cited on this visit.

An exit interview was conducted, and a copy of the report was furnished to staff Rosalia Delacruz and Ian Andres.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2022
LIC809 (FAS) - (06/04)
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