198320492-8-8-2024-11-AS-ZBRN-D7XQYJ-20240808123514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320492
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:39:51 PM

Document Has Been Signed on 08/08/2024 03:39 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	CERISE GUEST HOME		FACILITY NUMBER:	198320492
ADMINISTRATOR:	DEMAFELIX, JEHN MARIC		FACILITY TYPE:	740
ADDRESS:	22525 CERISE AVENUE		TELEPHONE:	(310) 533-1131
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 6	DATE:	08/08/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Jehn Maric Demafelix		TIME COMPLETED:	12:45 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 08/08/2024 at 9:20am, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager Janae Hammond conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA Zina Brown met with applicant Jehn Maric Demafeliz. An application was submitted to CCLD on 04/25/2024, for an Residential Care Faciity for the Elderly (RCFE) to serve elderly residents and dementia adults for ages 60 and over. The requested capacity is for six (6) bedridden residents. Structure: The facility is a (6) bedroom, (3) bathroom, single story house with a attached garage. The facility is a structure with 6 bedrooms, 3 bathrooms, 1 living room with a TV, and activity room with a TV and board games, a kitchen,and a backyard accessible to residence. There is backyard with a generator, two (2) outside shaded patio areas with a water fall outside on the premises. The resident three (3) bedrooms are spacious and will easily accommodate the residence furnishings. Bedroom Structure All six (6) bedrooms have the following one (1) bed, one (1) lamp, one (1) television, one(1) dresser, one (1) one (1) chair and signal auditory alarm one (1) each sliding door expect for Room F. Room B and Room C residents have a shared bathroom. Bathroom Structure All three (3) bathrooms have a working toilet, wash basin, shower with a rail and a slip grip map and shower chair. All (3) bathrooms can accommodate non-ambulatory clients in a wheel chair. Water temperature for each bathroom are as followed bathroom #1 113.2 F, bathroom #2 116.4 F and bathroom # 3 119.3 F

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina Brown	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CERISE GUEST HOME	FACILITY NUMBER: 198320492
	VISIT DATE: 08/08/2024

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in the garage.

Emergency Phone Numbers, Exit Plan & Menu:
The facility has a working phone line and internet. Upon entering the facility to the left of the walkway, is a posted board that & readily available with a evacuation plan, fire prevention, emergency plan, infection control plan and personal right. Fire Extinguisher is located in kitchen door mounted on wall which is fully charged.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer near the refrigerator. Food supply adequate stored in cabinet and consists can goods. The water temperature in the kitchen is at 117.1 F. Dishwasher in kitchen properly installed and functioning.

Smoke Detectors:
In the facility there are nine (9) smoke detectors with carbon monoxide detectors that are electrical & connected. Battery operated & working.

Appliances:
In the facility is a working stove burners, oven, microwave, washer, and dryer. There is one (1) refrigerator in the kitchen that is measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. In the garage is washer and dryer which stores linen for the bedding. The residence is equipped with central air and heat and each client bedroom is individually climate controlled.

Toxins:
All toxins are locked and stored in.

Water Temperature:
The water in each bathroom tested at 113.2 degrees Fahrenheit (bathroom 1), 116.4 degrees Fahrenheit (bathroom #2) and 119.3 degrees Fahrenheit (bathroom #3).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina Brown	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CERISE GUEST HOME	FACILITY NUMBER: 198320492
	VISIT DATE: 08/08/2024

NARRATIVE

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Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in kitchen area, available for staff use but inaccessible to residence.

Clients & Staff Files:

At the time of pre-licensing, no client and staff files were reviewed as the facility is awaiting approval for licensing.

Reading Material, Games, Equipment & Materials:
The facility has activity with board games, books, and other recreational materials for the client's use. commensurate with the plan of operation.

Pool/Jacuzzi & Pets:
No located at the time of inspection.

Fire clearance:
Fire clearance for six (6) bedridden at the residential care facility for the elderly was approved on 05/20/2024. In five (5) bedrooms each have a sliding door with a auditory alarm.

Pre-licensing Checklist: Completed by licensee and reviewed by LPA.

Component III:
During the conducted pre-licensing visit, an orientation of the component III information was provided to the licensee and employees about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA Zina Brown will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina Brown	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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