198320294-11-17-2022-11-AS-WGIS-CL9NKU-20221117093231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320294
Report Date: 11/16/2022
Date Signed: 11/17/2022 09:32:48 AM

Document Has Been Signed on 11/17/2022 09:32 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ACTIVE CARE HOME 1		FACILITY NUMBER:	198320294
ADMINISTRATOR:	CANTORIA, MARIA L.		FACILITY TYPE:	735
ADDRESS:	20545 MADISON ST.		TELEPHONE:	(310) 370-3748
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 6		CENSUS: 0	DATE:	11/16/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Robert Cantoria		TIME COMPLETED:	01:00 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 11/16/2022, Licensing Program Analysts (LPA) Wendy Gibbs conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 04/20/2022 for an initial license for an Adult Residential Facility to Developmentally Disabled Adults for ages 18-59 years. The requested capacity is for (6) clients, four (4) non-ambulatory and two (2) bedridden. Structure: The facility is a single-story house with four (4) bedrooms, three (3) full bathrooms, an office, living room, dining room, office space, kitchen, pantry and attached garage. Physical Plant The front entrance has a ramp that leads to the front door. The front landscape is in good condition. The front is clean and clear of obstructions and debris. There is a ramp out the back door that leads to the back yard. Outside they have tables and chairs for clients to sit. The back landscape is in good condition. All walkways are free of obstructions and debris. Bedrooms: All bedrooms have the required furniture: bed with proper linens, nightstand, lamp, dresser for individual residents, chairs for individual residents, and large closets in each room. Rooms 2 and 3/4 (same room, two entrances) are furnished for 2 residents.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

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

FACILITY NAME: ACTIVE CARE HOME 1	FACILITY NUMBER: 198320294
	VISIT DATE: 11/16/2022

NARRATIVE

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Bathrooms: Bathroom 1 (between rooms 1 and 2) is in good working condition. The toilet flushes, sink ran hot and cold, and shower had running water. The shower has a non-skid mat and secured grab bars. The water temperature measured 115.4 degrees Fahrenheit. It has a fully stocked with hand soap, paper towels, and hygiene products. Bathroom 2 (attached to room 5 and pantry) was in good condition. The toilet flushed and the shower ran hot and cold. The sink was shut off due to licensee (Robert) in the process of changing a valve. All bathrooms have a trash can with lids. The shower had a non-skid mat and secured grab bars. Bathroom 3 (attached to resident rooms 3/4) is in good working order. The toilet flushes, sinks runs hot and cold, and shower had running water. The shower had secured grab bars and a non-skid mat. Water temperature measured 116.1 degrees Fahrenheit.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in each resident’s room. In a cabinet there are an ample supply of towels and wash cloths.

Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in dining room bulletin board. Facility has a land line telephone located in the living room area. 2 Fire extinguisher, one mounted in kitchen pantry and the second mounted in room 2 by the exit. There is also fire sprinklers system throughout the facility.

Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked drawer in the kitchen. Adequate food supply is stored in kitchen and consists of the following: 4-day perishables, and 7-day non-perishables

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

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: ACTIVE CARE HOME 1	FACILITY NUMBER: 198320294
	VISIT DATE: 11/16/2022

NARRATIVE

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Appliances: Stove burners, oven, microwave, and washer/dryer are in working condition. There is one refrigerator in the home. The facility is equipped with central heat and air conditioning.

Toxins: Cleaning supplies, and toxins are stored in locked cabinet in the kitchen.

Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in the dining room with lock. The first-aid kit has been inspected and has at the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored with medication in the dining room, available for staff use but inaccessible to clients.

Clients & Staff Files: Designated area for files will be located in the front office in a locked cabinet.

Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises.

Fire Clearance: Fire clearance granted for four (4) non-ambulatory and two (2) bedridden, a total capacity of 6. Rooms approved for non-ambulatory/ bedridden, approval of delayed egress/secured perimeter/secure locked perimeter (if applicable). All exists have an egress on the doors.

Component III: Conducted at the Pre-Licensing visit.

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitor and temperature log for checks, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in cabinet. Resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, and required postings throughout the facility.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

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: ACTIVE CARE HOME 1	FACILITY NUMBER: 198320294
	VISIT DATE: 11/16/2022

NARRATIVE

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The following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA Lourdes Montoya, by 11/3022. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

List your correction for them

1. Sink in bathroom 2 needs to have running water.

2. Fix closet door in room 3/4.

3. Covers over fixtures in bathroom 3.

4. Light stove top without lighter.

An exit interview was conducted, and a copy of this report has been given to the applicant.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC809 (FAS) - (06/04)

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