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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320034
Report Date: 10/01/2022
Date Signed: 10/01/2022 11:40:34 AM

Document Has Been Signed on 10/01/2022 11:40 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:CN HOME #5FACILITY NUMBER:
198320034
ADMINISTRATOR:MATHARU, PRITAMFACILITY TYPE:
735
ADDRESS:2207 ARLINGTON AVETELEPHONE:
(310) 612-0978
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 3DATE:
10/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:FERNANDO CALLEJASTIME COMPLETED:
12:00 PM
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On 10/1/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit. Upon arrival at the facility, LPA Montoya called Administrator Fernando Callejas and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed to serve four (4) non-ambulatory clients, ages 18-59, developmentally disabled. LPA observed three (3) clients and three (3) staff present during today's visit. The facility's annual fees are current.

LPA toured the single-story facility with Administrator Callejas. The facility consists of four (4) bedrooms, four (4) bathrooms, a dining area, a living room, an office, and a activity room.

LPA Montoya toured and inside and outside grounds of the facility with Administrator Callejas. LPA observed 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, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115.8 and 117.4 degree Fahrenheit in the common bathrooms. A comfortable temperature was maintained in the facility.



LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (1) fire extinguisher that was charged and last serviced on 3/1/2022, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 9/15/2022. A working telephone (310) 328-8365 remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2022
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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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: CN HOME #5
FACILITY NUMBER: 198320034
VISIT DATE: 10/01/2022
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, 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. The facility has an approved Mitigation Plan Report on file with CCLD.

An exit interview was conducted with Administrator Fernando Callejas, and a hard copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2022
LIC809 (FAS) - (06/04)
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