<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202435
Report Date: 10/09/2022
Date Signed: 10/09/2022 11:58:21 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/09/2022 11:58 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MARIPOSA HOUSE (HFL HARBOR GATEWAY HOMES)FACILITY NUMBER:
198202435
ADMINISTRATOR:LIESS, CAROL MFACILITY TYPE:
735
ADDRESS:21218 MARIPOSA AVETELEPHONE:
(310) 781-3045
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 6CENSUS: 6DATE:
10/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lourdes Balolong TIME COMPLETED:
12:13 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/09/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with caregiver Lourdes Balolong and explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory clients between the ages of 18 through 59.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client rooms, one (1) office, one (1) staff room, three (3) bathrooms, two (2) living areas, one (1) dining area, laundry area, kitchen, and outside shaded patio area.

LPA and Balolong toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 109.9 F. A comfortable temperature of 75 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available. There are (3) fire extinguishers fully charged. Smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MARs) is observed to be maintained in order and accurate. Several landline phones were available and operable. The last Fire Drill was conducted on 09/27/22. A review of First Aid/CPR and Administrator's Certificate are maintained and current.

Evaluation Report continues LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2022
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: MARIPOSA HOUSE (HFL HARBOR GATEWAY HOMES)
FACILITY NUMBER: 198202435
VISIT DATE: 10/09/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. Review staff and clients’ vaccination observed to be maintained and accurate.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to caregiver Lourdes Balolong.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2