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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600054
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:05:22 PM

Document Has Been Signed on 05/12/2023 03:05 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BEVERLY TERRACEFACILITY NUMBER:
198600054
ADMINISTRATOR:ALICIA FLORES-GONZALEZFACILITY TYPE:
735
ADDRESS:1432 BEVERLY TERRACETELEPHONE:
(323) 721-2486
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 4CENSUS: 4DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff Maria GamboaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Maria Gamboa and explained the reason for the visit. The purpose of the visit is to complete the required inspection.
Shortly thereafter Administrator Alicia Flores-Gonzalez arrived.
LPA Trueman toured the facility along with Staff Maria Gamboa today 05/12/2023 at 12:20 PM and the following was observed:
Facility contains 2 Client Bedrooms and 1 Bathroom, dining room, living room, TV room, and activity room.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention.
Interviews were conducted with 3 clients and 2 staff. 4 client files and 3 staff files were reviewed
All staff were cleared and associated.
Medication was administered per physician's directions.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Staff responsible for providing care and supervision received training in First Aid.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
No deficiencies.
Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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