198320248-2-15-2022-11-AS-LMOA-CBNULJ-20220215144048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320248
Report Date: 02/15/2022
Date Signed: 02/15/2022 02:40:59 PM

Document Has Been Signed on 02/15/2022 02:40 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
MONTERY PARK, CA 91754

FACILITY NAME:	CABRILLO GUEST HOME		FACILITY NUMBER:	198320248
ADMINISTRATOR:	GARALDE, EDNA		FACILITY TYPE:	740
ADDRESS:	23731 CABRILLO AVENUE		TELEPHONE:	(310) 325-7610
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 5	DATE:	02/15/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jehn Maric Demafelx		TIME COMPLETED:	01:45 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 2/15/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced visit to this home. LPA was greeted by applicant representative Jehn Maric Demafelix and explained the purpose of today’s pre-licensing inspection visit.

An application was submitted to CCLD on 12/20/20 for the initial license application for a Residential Facility for the Elderly. The applicant requested a capacity of six (6) individuals, of which six (6) are non-ambulatory.

LPA Montoya conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist, and Component III Orientation.

Structure:

The facility is a 2-story house located in a residential neighborhood and consists of four (4) bedrooms, two (2) bathrooms and a two (2) car garage on the first floor; the second floor consists of five (5) bedrooms, three (3) bathrooms and a den. The home also consists of a living room, dining room, and kitchen on the floor first. The facility is clean, sanitary, and in good repair. Protective devices are in place to include non-slip material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees. Fireplaces and open-faced heaters are inaccessible to clients.

Bedrooms (Residents):

The facility has four (4) bedrooms for non-ambulatory clients. All rooms include (1) a bed, one (1) chair, one (1) nightstand, one (1) table lamp. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath, or toilet.

Evaluation Report Continues

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

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 3

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: CABRILLO GUEST HOME	FACILITY NUMBER: 198320248
	VISIT DATE: 02/15/2022

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

Bedrooms (Staff):
There are five (5) bedrooms on the second floor for live-in staff and a renter.

Bathrooms:
The home has two (2) bathrooms on the first floor for residents and three (3) bathrooms on the second floor for staff. All resident 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 and bathroom.

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 three (3) fire extinguishers located in the kitchen mounted on the wall, on the second floor and in the garage. A telephone line is available in the kitchen (310-325-7610). Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant’s Mitigation Plan was approved on 1/7/2022.

Food Service:
All kitchen areas are clean and free of litter, rodents, vermin, and insects. The refrigerator and freezer are clean and of adequate size. The freezer is maintained at 0 degrees Fahrenheit and the refrigerator is below the required maximum of 40 degrees Fahrenheit. A two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food were observed. All equipment, appliances, dishes, and utensils are clean and well maintained.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are operable.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet and in the garage.

Evaluation Report Continues

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CABRILLO GUEST HOME	FACILITY NUMBER: 198320248
	VISIT DATE: 02/15/2022

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

Water Temperature:
The water temperature is 120.00 degrees in the resident bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in a locked cabinet 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 are stored in a locked cabinet in the dining area.

Clients & Staff Files:
The applicant is not handling the cash resources of the residents. Records of staff and residents are stored in a locked cabinet in the dining 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 activity room.

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

Fire clearance:
A Fire Clearance inspection was conducted on 10/28/2021 with approval for a capacity of six (6) non-ambulatory. The most recent fire inspection was also conducted on 2/8/2022.

Component III:
LPA Montoya 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 representative Jehn Maric Demafelix. LPA Montoya 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

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3