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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600265
Report Date: 09/02/2021
Date Signed: 09/02/2021 01:38:54 PM

Document Has Been Signed on 09/02/2021 01:38 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:ERNIE'S PLACEFACILITY NUMBER:
198600265
ADMINISTRATOR:LAN LYFACILITY TYPE:
735
ADDRESS:630 N. NICHOLSONTELEPHONE:
(626) 280-7205
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 6CENSUS: 6DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Christian Trasvina, DSPTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an annual inspection visit with the focus of the Infection Control domain. LPA arrived unannounced and met with Christian Trasvina. The facility Administrator, Lan Ly, arrived shortly thereafter.
The facility is licensed for six Developmentally Disabled adults from 18-59 years old and is approved for 3 ambulatory and 3 non-ambulatory adults. This facility is vendorized through the Eastern Los Angeles Regional Center.

LPA Chan toured the facility with Mr. Trasvina and observed/inspected the following:
* This is a 2-story facility. Clients only reside on the first floor. The first floor consists of seven rooms, which six are individual client rooms and one staff office. There are also 3 bathrooms on this floor, a living room, kitchen, and laundry room. The second floor has 3 rooms and a bathroom, which are occupied as a supply storage room, Administrator's office, and the Health Care Coordinator's office.
* There are no bodies of water or pool at the facility. No items obstructing the walkways.
* There is an outside table setup with the Covid-19 (Coronavirus) symptom screening and temperature taken prior to entry. Another visitor log is filled out upon entry located by the door.
* LPA observed signage posted in the facility and in the bathrooms to promote hand washing.
* The hot water temperature was measured within the range of 105-120 degree F.
* Disinfectants are stored and locked in the laundry room. Knives are stored and locked in the kitchen cabinet.
* LPA observed sufficient food supply of 2-day perishable and a week of nonperishable.
* All staff on duty wore a face mask.
* Medications were reviewed for all 6 clients and are being administered as prescribed.

There are no deficiencies observed during the visit. An exit interview was conducted. A copy of this report along with the appeal rights were provided to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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