198320248-3-7-2024-11-AS-RCLD-D35TCR-20240307133710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320248
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:37:18 PM

Document Has Been Signed on 03/07/2024 01:37 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CABRILLO GUEST HOME		FACILITY NUMBER:	198320248
ADMINISTRATOR:	IRENE FORMENTERA		FACILITY TYPE:	740
ADDRESS:	23731 CABRILLO AVENUE		TELEPHONE:	(310) 325-7610
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 6	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Administrator Irene Formentera		TIME COMPLETED:	01:50 PM

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On 03/07/24 at 9:07 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with COO JM Demafelix. The Administrator Irene Formentera arrived later.

The facility is licensed to serve six (6) elderly residents, all of which (6) may be non-ambulatory with a hospice waiver approved for four (4) aged 60+ years.

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.

The Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 119.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

Continue to LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CABRILLO GUEST HOME	FACILITY NUMBER: 198320248
	VISIT DATE: 03/07/2024

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LPA toured the kitchen and garage area and observed a two day supply of perishable and a seven day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced September 26, 2023 was observed in the kitchen area. Administrator tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. Two staff interviews were conducted.

5 resident records were reviewed and, 5 out of 5 resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. Two residents were interviewed.

No deficiencies are being cited.

An exit interview was conducted and a copy of this report was discussed and left with Administrator Irene Formentera.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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