198320520-12-20-2024-11-AS-EDAT-DC5L3C-20241220072344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320520
Report Date: 12/18/2024
Date Signed: 12/20/2024 07:24:37 AM

Document Has Been Signed on 12/20/2024 07:24 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ERLINDA'S LEGACY HOMES 1		FACILITY NUMBER:	198320520
ADMINISTRATOR/ DIRECTOR:	JABONERO, JANICE R		FACILITY TYPE:	735
ADDRESS:	22237 CATSKILL AVE		TELEPHONE:	(562) 480-3539
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 4		CENSUS: 4	DATE:	12/18/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:41 PM
MET WITH:	Janice Jabonero		TIME VISIT/ INSPECTION COMPLETED:	03:32 PM

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On 12/14/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an announced pre-licensing visit at this home. LPA was greeted by administrator Janice Jabonero and explained the purpose of the visit.

An application was submitted to CCLD on 07/24/24. In the initial license application for a Residential Facility for Adults, ages ranging from 18-59 years old. The applicant requested for a capacity of four (4) ambulatory, (0) non-ambulatory, and zero (0) bedridden.

Structure:
Facility is four (4) bedrooms, two (2) bathrooms, one story home with a two (2) car attached garage situated in a cul-de-sac. The home is a light blue stucco structure which includes living, dining, laundry, and kitchen areas. The living room area has no fireplace. The living area also included sofa and coffee table. The kitchen is equipped with refrigerator and stove. The exterior rear is bricked fenced throughout. During the visit LPA noticed passageways, walkways to patio area are free from obstructions.

Bedrooms Clients:
The facility has four (4) bedrooms for clients. Bedrooms includes (1) twin size bed in each room. Room #1, #3 and #4 can accommodate for non-ambulatory clients if required. All rooms have one (1) chair, one (1) nightstand, one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which comply with the requirement of 8 cubic feet of space. All rooms had closets for ample storage.

Bedrooms Staff:

No designated bedroom for staff.

(Evaluation Report continues LIC 809C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

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: ERLINDA'S LEGACY HOMES 1	FACILITY NUMBER: 198320520
	VISIT DATE: 12/18/2024

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Bathrooms:
The facility had two (2) bathrooms. Bathroom #1 is for clients in the hallway accessible to bedroom #4. Bathroom #2 is accessible to bedroom #1, #2 and #3. All bathrooms have a working toilet, wash basin, and shower non-skid mats and grab bars.

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 and hallway closets.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers, exit plan and menu are posted and readily available for review in the kitchen room area. There are two (2) fire extinguishers located in the activity and living rooms on the wall and are fully charged. The interior is also equipped with fire sprinklers throughout the home. A telephone landline system is available.

Food Service:
Dishes, cups and flatware are stored in the kitchen cabinets, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked closet adjacent to the kitchen area. Food supply adequate stored in kitchen cabinets and consists of the following: can meats, can sauces, variety of cereal boxes, beans and rice. The kitchen counters also had small appliances which includes a countertop microwave.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior home. Hardwired smoke detectors in all four (4) bedrooms. Carbon monoxide a total of two (2) in the hallway and kitchen area.

Appliances:

Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which includes a microwave. There is one (1) refrigerator located in kitchen, activity room and garage. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (45) zero degrees Fahrenheit. The residence is equipped heating and individual wall mounted air condition system and ceiling fans.

(Evaluation Report continues LIC 809C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: ERLINDA'S LEGACY HOMES 1	FACILITY NUMBER: 198320520
	VISIT DATE: 12/18/2024

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Toxins:
All toxins are locked/stored in cabinet in the garage and in kitchen cabinets.

Water Temperature:
Bathroom #1 tested at 106.1-degree F. Bathroom #2 tested at 106.0-degree F.
Medications, First-Aid Kit & Book:
A first aid kit stored in office closet has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual locked in closet. Client's medications are stored in the dining room area in a metal locked cabinet and inaccessible to clients.

Clients & Staff Files:

Applicant is handling cash resources of clients and will be stored in the office closet. Records of staff and clients will be stored in a office closet. The home handles client’s cash resources and has a current Surety Bond effective 07/27/24 and current Certificate of Liability Insurance effective 05/27/24 – 05/27/25.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the client's use all stored in the common area in living room area and the activity room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi or pool in the fenced area.

Fire clearance:

Fire Clearance was on 12/17/24 with approval for a capacity four (4) ambulatory. Fire Drills are conducted quarterly with the last drill dated 09/01/24.

Component III:
(LPA) Dabuet conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.
(Evaluation Report continues LIC 809C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

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: ERLINDA'S LEGACY HOMES 1	FACILITY NUMBER: 198320520
	VISIT DATE: 12/18/2024

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

End of Report

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC809 (FAS) - (06/04)

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