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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600450
Report Date: 11/14/2022
Date Signed: 11/14/2022 04:02:11 PM

Document Has Been Signed on 11/14/2022 04:02 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:SALEM HOMEFACILITY NUMBER:
198600450
ADMINISTRATOR:COX, LUCILA C.FACILITY TYPE:
735
ADDRESS:14006 DUMONT AVENUETELEPHONE:
(562) 929-2811
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator- Lucila CoxTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ashley Calderon and KImberly Ramirez made an unannounced visit to the facility to conduct a 1 year required inspection. LPA's explained the purpose of today’s visit and was greeted by Administrator Lucila Cox.

The home consist of four (4) client bedrooms, one (1) staff room, three (3) bathrooms, activity room, attached garage used for storage and laundry, living room, kitchen, and dining room. LPA's observed that the facility fire extinguisher was up to date , fire alarm and oxygen monoxide up to date and operable. Backyard has no bodies of water that pose a risk to clients in care. There are no firearms being stored at this location.

LPA's verified last Fire Drill was conducted on 11/9/2022. Administrator Certificate expires on 7/29/23.

LPA's along side with Administrator toured the physical plant: the kitchen and food supply had adequate supply for more than two day supply of perishables and a seven day supply of non-perishables foods on hand. There is additional food supply in storage. LPA's observed locked drawer for sharp items and medication in the kitchen and cleaning supplies locked in the garage inaccessible to clients.

LPA's reviewed medication and it was observed all medication was labeled and meet regulation requirements. LPA's reviewed three employee files, no issues. LPA observed appropriate Covid-19 posters around the facility, symptom screening and PPE located front of the home entrance. PPE sufficient for 90 days +. LPA's and Administrator reviewed Inspection Control Tool.

No deficiencies cited at the above home. An exit interview was held with Lucila Cox and a copy of this report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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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