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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600450
Report Date: 08/23/2024
Date Signed: 08/23/2024 11:29:47 AM

Document Has Been Signed on 08/23/2024 11:29 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SALEM HOMEFACILITY NUMBER:
198600450
ADMINISTRATOR/
DIRECTOR:		COX, LUCILA C.FACILITY TYPE:
735
ADDRESS:14006 DUMONT AVENUETELEPHONE:
(562) 929-2811
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Lucila Cox, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:47 AM
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Licensing Program Analyst (LPA) Sanjay Vaid conducted the required annual inspection. LPA arrived unannounced and met with Lucila Cox (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 4 developmentally disabled adults ages 18 to 59 years old.

The facility is a single-story home located in a residential area. A tour of the facility includes living room, dining area, kitchen, den, 4 client bedrooms, 3 bathrooms (1 bathroom inside client room), 1 staff room, staff office, attached garage with laundry, front yard, backyard and locked tool shed.

LPA utilized the Compliance and Regulatory Enforcement tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: There are 4 client bedrooms, 3 bathrooms (1 bathroom inside client room), 1 staff room, staff office, living room, dining area, kitchen, den, attached garage with laundry, front yard, and backyard. Bathrooms are clean and operational. Clients’ bedrooms were checked accommodate for each client comfortable was visible. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed
at the facility. There are no weapons on the premises. The hot water temperature was tested in all bathrooms and kitchen measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to clients. The last Fire/Emergency Drill was conducted on 07/05/24. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged, last serviced on 05/06/2024. Operational Requirements: The facility has an approved fire clearance and outdoor activity area that is shaded and furnished for outdoor use. Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Lucila Cox certificate expired 7/2/2025.

Continued on 809 C......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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: 198600450
VISIT DATE: 08/23/2024
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Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and ongoing training. Staff files are maintained at the facility and kept in the staff office. Reviewed three (3) staff files, all certificates and health documents are up to date. Client Rights-Information: Clients are provided with telephone and internet at the facility. Client Records-Incident Reports: Client files are kept in a secure location within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Health Related Service: Staff designated to administer medication has the proper training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed 2 clients’ medication no issues were observed. Reviewed four (4) clients files no issues were observed. Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency Intervention: Clients at this facility do not require the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to Administrator Lucila Cox.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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