198320248-3-14-2023-11-AS-MLEN-CPWUZB-20230314160117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320248
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:01:31 PM

Document Has Been Signed on 03/14/2023 04:01 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:	CABRILLO GUEST HOME		FACILITY NUMBER:	198320248
ADMINISTRATOR:	GARALDE, EDNA		FACILITY TYPE:	740
ADDRESS:	23731 CABRILLO AVENUE		TELEPHONE:	3103257610
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 4	DATE:	03/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:11 AM
MET WITH:	Jehn Maric (JM) Demafelix - Licensee		TIME COMPLETED:	04:27 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 3/14/2023, Licensing Program Analyst (LPA) Mario Leon made an unannounced Required - 1 Year inspection to the above residential care facility for the elderly (RCFE). LPA Leon met with Jehn Maric (JM) Demafelix, Licensee (L1). LPA Leon informed staff that the purpose of today's visit was to inspect the RCFE physical plant, review staff and client’s records. The facility is licensed to serve six (6) elderly clients, all of which (6) may be non-ambulatory with a hospice waiver approved for four (4) aged 60+ years. LPA and L1 toured the facility, inside and out. 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 first floor. The facility is clean, sanitary, and in good repair. Protective devices are in place, including non-slip mats and grab bars in all showers. 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 maintains a comfortable temperature at 76.8 F. Fireplaces and open-faced heaters are properly screened and required documents are posted as mandated by the DPH and CCLD. Smoke detectors and carbon monoxide detector are in compliance and operational. No firearms are stored at the facility and no bodies of water are present. Medications are centrally stored, locked and inaccessible to clients. Staff files are current, resident files are also current along with medications admissions record (MARs). The water temperature was measured at 114.2 F in bathroom number one (1). Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequat with hazardous toxins and/or sharp items being inaccessible to clients, 3 fire extinguishers are fully charged and the last fire / earthquake drill was conducted on 2/17/2023. First Aid kit and supplies are complete. See LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CABRILLO GUEST HOME	FACILITY NUMBER: 198320248
	VISIT DATE: 03/14/2023

NARRATIVE

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in all bathrooms and additional sanitation supplies located in the attached garage. LPA observed staff wearing masks and an isolation room (clients can isolate in own room if necessary, with bedroom number four (4) vacant and designated as the isolation room). The facility has an approved Mitigation plan. Visitors are screened, logged and checked with a short questionnaire at the front entrance.

There were no deficiencies cited today.

An exit interview was held and this report was provided to Licensee, Jehn Maric (JM) Demafelix.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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