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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600477
Report Date: 12/23/2022
Date Signed: 12/23/2022 12:42:50 PM

Document Has Been Signed on 12/23/2022 12:42 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CAREMORE AID & BOARD FACILITYFACILITY NUMBER:
198600477
ADMINISTRATOR:RONALD F ZABLOCKIFACILITY TYPE:
735
ADDRESS:14807 LEMOLI AVENUETELEPHONE:
(424) 269-1632
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 8CENSUS: 7DATE:
12/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Rolando Bundalian - Direct CaregiverTIME COMPLETED:
01:00 PM
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On 12/23/22, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA Leon met with the Direct Caregiver Rolando Bundalian (S1). LPA explained the purpose of today’s visit. The facility is licensed to operate for (8) ambulatory adults ages 18 through 59. Currently, seven residents reside at this facility.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: six (6) bedrooms (one staff bedroom and five client bedrooms) two bathrooms, living area, dining area, kitchen, and outside patio area. LPA toured the physical plant along with S1. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 108.3 F in bathroom one (1) and 109.4 F in bathroom two (2).

Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available, stored properly. Two fire extinguishers were charged, smoke detectors and carbon monoxide were operable.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff was wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed.
See LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CAREMORE AID & BOARD FACILITY
FACILITY NUMBER: 198600477
VISIT DATE: 12/23/2022
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LPA advised S1 to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed. There was one technical advisory note provided, see LIC9102

Exit interview held. A copy of the report was provided to Rolando Bundalian (S1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
LIC809 (FAS) - (06/04)
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