198320140-4-19-2022-11-AS-SCAS-CDMKYD-20220419081859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320140
Report Date: 04/18/2022
Date Signed: 04/19/2022 08:19:49 AM

Document Has Been Signed on 04/19/2022 08:19 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	FLORIAN HOUSE ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198320140
ADMINISTRATOR:	MBANALU, EJIKE		FACILITY TYPE:	735
ADDRESS:	17602 CRABAPPLE WAY		TELEPHONE:	(661) 313-9388
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY:	4	CENSUS: 0	DATE:	04/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:57 PM
MET WITH:	Ejike Mbanalu		TIME COMPLETED:	04:30 PM

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On 04/18/22, at 2:57 pm, Licensing Program Analyst (LPA) Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Ejike Mbanalu, and explained the purpose of today’s visit. This facility is licensed to serve (4) Non- ambulatory Developmentally Disabled Adults age 18 – 59. Currently, the home has (0) clients living in the facility. The LPA inspected the inside/outside of the facility grounds. The residential home facility is located in a residential community that consists of a two floor structure with 4 bedrooms, 3 bathrooms, kitchen, dining room, living room, family den, 2nd floor den/ office area, laundry room and an attached garage.

LPA and Mr. Mbanalu 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 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 hot water temperature measured 110.4 degrees Fahrenheit. A comfortable temperature of 75 degrees Fahrenheit 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 available and maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FLORIAN HOUSE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198320140
	VISIT DATE: 04/18/2022

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents 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.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Administrator Ejike Mbanalu

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC809 (FAS) - (06/04)

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