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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320069
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:44:08 PM

Document Has Been Signed on 05/05/2023 02:44 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:CN HOME #10FACILITY NUMBER:
198320069
ADMINISTRATOR:CALLEJAS, GLORIAFACILITY TYPE:
735
ADDRESS:25022 PRESIDENT STTELEPHONE:
(424) 250-9638
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 4CENSUS: 4DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Gloria CallejasTIME COMPLETED:
03:00 PM
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On 05/05/2023, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with administrator, Gloria Callejas 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 clients are Harbor Regional Center clients. Two clients have Restricted Health Care Conditions, and none are utilizing postural supports or protective devices. The facilities annual fees are current.

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 conducted a records review of (4) client records, (6) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

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 measured within Title 22 guidelines. A comfortable temperature was maintained in the facility.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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: CN HOME #10
FACILITY NUMBER: 198320069
VISIT DATE: 05/05/2023
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for cleaning supplies, toxins, and sharps were stored, locked, and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available which was 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. The facility had the required postings throughout the facility. The last fire/emergency drill was conducted on 04/28/2023.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff was wearing face coverings, and the required postings were posted throughout the facility. LPA observed the facility has a 60-day supply of Personal Protective Equipment (PPE). LPA’s temperature was taken and screening questions for COVID-19 were asked before LPA was allowed to enter the facility.



LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of this report was provided to Administrator, Gloria Callejas.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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