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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204800
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:39:06 PM

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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MY MOTHER'S PLACEFACILITY NUMBER:
198204800
ADMINISTRATOR:HILDA LOZANOFACILITY TYPE:
740
ADDRESS:11827 ROSE AVENUETELEPHONE:
(310) 707-7768
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
02:00 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 11/19/2021, Licensing Program Analyst (LPA) Ngozi Nwaokoro conducted an unannounced Annual required visit to My Mother’s Place Facility. LPA was met by Licensee Hilda Lozano and the purpose of today’s visit was explained, unannounced Required- 1-year inspection, with emphasis on infection control. As a part of the inspection, LPA reviewed client records, staff records, medications, and inspected the entire facility.

The facility is licensed for six non-ambulatory residents, and currently houses five (5) residents. LPA inspected the physical plant with the Administrator, including but not limited to the kitchen, a total of six bedrooms in the home for residents; and two staff present. LPA inspected the laundry area, garage, and backyard area. LPA observed the facility to be free of odor, clean and in good repair, and no bodies of water were observed.



All client rooms were checked, mattresses and box springs were in good condition, adequate lighting, dresser, and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients. Water temperature properly measured between 105*-120F* (105*).

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was operational. Smoke detectors were working properly, three fire extinguisher was fully charged and operational, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit with manual was checked and in order. Shaded outside area was accessible to clients.


No deficiencies cited during this visit.


Exit interview conducted and a copy of this report was given to the Administrator, Hilda Lozano at the time of visit.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Ngozi NwaokoroTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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