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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320069
Report Date: 05/17/2022
Date Signed: 05/17/2022 06:25:03 PM

Document Has Been Signed on 05/17/2022 06:25 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CN HOME #10FACILITY NUMBER:
198320069
ADMINISTRATOR:MATHARU, DAVEFACILITY TYPE:
735
ADDRESS:25022 PRESIDENT STTELEPHONE:
(310) 612-0978
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 4CENSUS: 1DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:House Manager - Gloria CallejasTIME COMPLETED:
03:00 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 05/17/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with House Manager Gloria Callejas and Administrator Dave Matharu and explained the purpose of today’s visit. The facility is licensed to operate for four (4) adult clients of between the ages of 18 through 59.


The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, two (2) office spaces with one in the kitchen area and the other in a separate closed door area, three (3) bathrooms, two (2) living areas, a dining area and kitchen. There is an outside covered patio area in the backyard with ample seating. The laundry area is located near the rear between rooms #2 and #3. The garage is detached with access from a door and used for storage. There is also a detached storage area behind the garage.


LPA and Administrator 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 provided, storage for client 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 met Title 22 standards in the bathrooms and kitchen sink and measured between 114.3 F to 116.3 F. A comfortable temperature was maintained in the facility.


Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CN HOME #10
FACILITY NUMBER: 198320069
VISIT DATE: 05/17/2022
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
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 clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There is one (1) fire extinguisher fully charge located next to the front door entrance. Smoke detectors and carbon monoxide were operable and in working condition. A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate.


During the visit, LPA observed the facility infection control practices. LPA observed hand sanitizer available and temperature taken upon entry to the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). There is a fully stocked first aid kit in the office room.


No deficiencies were cited during this inspection visit.


An exit interview was conducted and a copy of this report was provided to Administrator Dave Matharu.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2