198320223-9-29-2021-11-AS-EDAT-C7BHSP-20210929062729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320223
Report Date: 09/28/2021
Date Signed: 09/29/2021 06:28:24 AM

Document Has Been Signed on 09/29/2021 06:28 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
MONTERY PARK, CA 91754

FACILITY NAME:	EMILY'S HOMECARE		FACILITY NUMBER:	198320223
ADMINISTRATOR:	FIGUEROA, PATRICK		FACILITY TYPE:	735
ADDRESS:	603 W. 235TH ST		TELEPHONE:	(310) 938-6193
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 4		CENSUS: 0	DATE:	09/28/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	PATRICK FIGUEROA		TIME COMPLETED:	02:17 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 09/28/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an announced visit to this home. LPA was greeted by applicant Patrick Figueroa and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 06/14/21. In the initial license application for a Residential Facility for Adults, ages ranging from 18-59 years old. The applicant requested for a capacity of four (4) individuals, of which three (3) ambulatory, one (1) non-ambulatory, and zero (0) bedridden. Structure: The home is a five (5) bedroom, two (2) bathroom, one-story home with a one (1) car garage situated in a residential neighborhood. The home is a mustard color structure that includes living, dining, kitchen, and laundry area. The living room area has no fireplace. The living area included sofas and a table. The kitchen has marble countertops with a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. The patio is covered with a table and four (4) chairs and an umbrella for shade. Bedrooms Clients: The facility had four (4) bedrooms for clients. There are three (3) bedrooms for ambulatory clients and (1) one-bedroom for a non-ambulatory clients. All rooms include (1) a full-size bed, one (1) chair, one (1) nightstand, one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: EMILY'S HOMECARE	FACILITY NUMBER: 198320223
	VISIT DATE: 09/28/2021

NARRATIVE

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Bedrooms Staff:
There is one (1) rear bedroom designated for live-in staff.

Bathrooms:
The home has two (2) bathrooms. Bathroom #1 is accessible to bedrooms #1-#4 through a hallway. Bathroom #2 is for staff only. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet adjacent to the client’s bedrooms.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are two (2) fire extinguishers located in the kitchen mounted on the wall the other is in the garage and fully charged. A telephone line is available in the living room area.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer next to the stove. Food supply is adequately stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide a total of one (1) is located in the hallway.

Toxins:
All toxins are locked/stored inside the hall closet.

Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: EMILY'S HOMECARE	FACILITY NUMBER: 198320223
	VISIT DATE: 09/28/2021

NARRATIVE

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Appliances:
Stove burners, oven, microwave, washer, and dryer working. The kitchen counters also had small appliances which include a toaster, blender, coffee maker, and rice cooker. There is one (1) refrigerator in the home. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. A second refrigerator is located in the garage for backup food supplies. The residence is equipped with central air and heat.

Water Temperature:
The water temperature is 110.7 degrees throughout the kitchen and bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the dining cabinet has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to clients. The client's medications will be stored in the same cabinet locked in the dining area cabinet and inaccessible to clients.

Clients & Staff Files:
The applicant is handling the cash resources of clients and will be stored in a locked cash box inside a locked cabinet in the dining room area. Records of staff and clients will be stored in a free-standing mental cabinet in the dining room area.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the client's use all stored in the living room, commensurate with the plan of operation.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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
MONTERY PARK, CA 91754

FACILITY NAME: EMILY'S HOMECARE	FACILITY NUMBER: 198320223
	VISIT DATE: 09/28/2021

NARRATIVE

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Fire clearance:
A Fire Clearance inspection was conducted on 08/26/21 with approval for a capacity for three (3) ambulatory, one (1) for non-ambulatory, and zero (0) for bedridden.

Component III:
LPA Dabuet conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

LPA observed no corrections during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Patrick Figueroa. LPA Dabuet will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

END OF REPORT

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC809 (FAS) - (06/04)

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