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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600140
Report Date: 02/11/2025
Date Signed: 02/11/2025 03:33:56 PM

Document Has Been Signed on 02/11/2025 03:33 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SALEM HOMEFACILITY NUMBER:
198600140
ADMINISTRATOR/
DIRECTOR:
DELORES BERINTIFACILITY TYPE:
735
ADDRESS:4122 KIMA CTTELEPHONE:
(562) 634-1256
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 1DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Bertha Duarte, Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today, using the CARE Tool. LPA met with Bertha Duarte, Direct Support Staff and Administrator Ronald Bautista arrived thereafter and assisted with the tour of the facility. The reason for the visit was explained. The physical plant was inspected along with client and staff records, food supply and medication. The facility is licensed to serve 2 non-ambulatory and 2 ambulatory clients in the age range of 18 through 59. Clients receive services through Harbor Regional Center. The facility is operating within the scope of its license. Currently, the facility provides services to three clients. One client was present during the visit and two clients were away at day program. The facility is a single home, located within a residential neighborhood.

LPA observed the following during today's visit:

The home is made up of four client bedrooms, two bathrooms, living room, staff office space, kitchen and dining area. Client bedrooms (four) have the required furniture such as bed frames, dressers, adequate lighting, and chairs. Bedrooms also have sufficient closet space. Beds have the required linen, and linen is in good condition. Extra linen and personal hygiene supplies were observed in hallway closet. The water temperature in both bathrooms was tested and observed to be 105 - 105.7 degrees F which is within the required regulation of 105 - 120 degrees F. The living room furniture is clean and in good repair. Exercise equipment was observed in the living room, operable and accessible to clients. The kitchen was observed to be clean and for the ability to prepare and serve food. Appliances in the kitchen were clean and functional. The pantry was stocked with sufficient food and labeled for use within expiration limits. Sufficient supply of 2 days perishable & 7 days non-perishable food was observed in the kitchen and in the garage overflow refrigerator. Sharps and cleaning supplies were observed to be locked in a kitchen cabinet and inaccessible to clients. Attached garage is kept locked. The garage houses a laundry area which is equipped with one washer and one dryer. Both appliances were operable during visit. Laundry liquids are kept locked in garage storage cabinet.

***Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SALEM HOME
FACILITY NUMBER: 198600140
VISIT DATE: 02/11/2025
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The outdoor environment which consists of a front and backyard was observed to be well maintained and there are no pools or large bodies of water. A shaded and seating area located in the back patio is available and accessible to clients. Passageways and exits are free of obstruction. Smoke and carbon monoxide detectors were observed throughout the facility and were tested and operable during the visit. There is one fire extinguisher in the dining area which was observed to be charged.

Medications are centrally stored and locked in a medication cabinet in the hallway. Three staff and three client files were reviewed during today's visit. Staff working at facility have fingerprint clearances.

No deficiencies observed during today’s inspection. Exit interview was conducted with Ronald Bautista, Administrator. A copy of this report was issued today.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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