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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320037
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:44:59 PM


Document Has Been Signed on 01/03/2024 03:44 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:CARMIE HOME CAREFACILITY NUMBER:
198320037
ADMINISTRATOR:RECIO, PAOLOFACILITY TYPE:
735
ADDRESS:14528/30 HALLDALE AVETELEPHONE:
(310) 938-2190
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:9CENSUS: DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosauro Deguzman, CaregiverTIME COMPLETED:
03:45 PM
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On 1/3/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA was met by Caregiver Rosauro DeGuzman and explained the purpose of today’s visit. The facility is an ARF licensed for nine (9) ambulatory clients.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: (4) resident bedrooms, (2) resident bathrooms, (1) staff bedroom, living room, dining room, kitchen, detached garage/storage, laundry room, and shaded outdoor seating area with table and chairs.

LPA Shirley and Rosauro walked through the kitchen and all appliances were in good working order. Knives were locked and stored under the sink in the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured *****degrees Fahrenheit.

Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. The facility is in good repair.

LPA Shirley and Rosauro walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen and hallway. The backyard is clean and clear of obstructions and hazards and there are no bodies of water present.

Documents are posted as mandated. No deficiencies cited at this time.


An exit interview was conducted, and a copy of this report was provided to Caregiver, Rosauro DeGuzman.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
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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