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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320369
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:27:55 PM

Document Has Been Signed on 07/14/2023 03:27 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:HIGHMORE CARE HOMEFACILITY NUMBER:
198320369
ADMINISTRATOR:GUIAO, JOSEFINAFACILITY TYPE:
735
ADDRESS:29306 S. HIGHMORE AVETELEPHONE:
(213) 880-1627
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 4CENSUS: 0DATE:
07/14/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Vilma GoTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Ruby Velasco and Licensing Program Manager I LPM Eva Alvarez, conducted an announced visit at the facility for the purpose of a pre-licensing evaluation. LPA and LPM met with Licensee/Vilma Go and Josefina Guiao during this visit.

An initial application for an Adult Residential Facility to support individuals with Developmental Disabilities for ages 18 to 59 was submitted to the Community Care Licensing Adult and Senior Program on 01/23/2023. The Licensee has obtained a fire clearance approval for (1) ambulatory adult and (3) non-ambulatory adults. Bedroom #4 is designated for (1) ambulatory adult and rooms #1,#2, and #3 are designated for non-ambulatory adults.

The facility is a (4) bedroom, (2) full bathrooms, a (1/2) bathroom single story house. The client bedrooms are furnished with required, bedding, tables, chairs, dressers, closets, and lamps for sufficient lighting. LPA observed a sufficient supply of linens, toiletries, bath towels stored in each client bedroom closet and laundry room cabinets. The bedrooms are located near front entrance in the home. All bathrooms have a working toilet, wash basin and shower. All bathrooms have working fixtures and one bathroom is designated for a non-ambulatory adult. The facility has a tankless water heater that is set at 110 degrees Fahrenheit. The facility kitchen, living room, and (2) dining areas are part of an open floor plan. The laundry room and ½ bathroom are in the rear area of the home. There is a (2) car garage that is being utilized as a storage area and staff office. The back yard has a covered patio with table and chairs accessible to clients. The back yard has a deck with additional seating and a table. LPA toured the backyard and observed all passageways are clear of obstruction.

LPA reviewed the facilities emergency disaster plan, infection control plan, first aid supplies, flashlights, and facility emergency exits. The facility has accessible fully charged fire extinguisher, as well as six dual functioning smoke with carbon monoxide detectors. LPA observed required postings are visible. LPA observed secured storage area for chemicals, medications, and sharp objects.

LPA observed sample menu, perishable and non-perishable food supply. LPA observed facility refrigerator and freezer are clean and sanitary. The refrigerator and freezer meet the temperature requirements.

LPA will notify Central Applications Unit of no corrections needed at this time.


Component III:
LPA conducted Component III orientation with Administrator/ Josefina Guiao on 7/14/2023. An exit interview was conducted and a copy of this report was provided to Administrator /Guiao.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ruby Velasco
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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