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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600534
Report Date: 11/22/2022
Date Signed: 11/22/2022 03:47:02 PM

Document Has Been Signed on 11/22/2022 03:47 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:PACENCIA HOMEFACILITY NUMBER:
198600534
ADMINISTRATOR:EILEEN CORREOSFACILITY TYPE:
735
ADDRESS:20507 HARVEST AVENUETELEPHONE:
(562) 221-9815
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eileen Vazuez Correos, facility directorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with facility director, Eileen Vazuez Correos, who assisted with the visit. The facility is to serve four (4) ambulatory developmentally disabled adults, age 18 through 59 years old. Annual fees are current. LPA discussed with facility director regarding the purpose of today's visit and the inspection.

All current clients were placed by Harbor Regional Center. Administrator certificate is current, expires on 9/16/2024.



During the visit, inspection tool: infection control domain was used, interviews conducted; a tour of the facility was conducted; food supply was reviewed; and medications were reviewed.

This is a single story home located at a residential neighborhood which consists of a front yard, living room, kitchen, dining room, family room, office area, two (2) bathrooms, four (4) bedrooms, and back yard with covered patio. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser, and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Hot water temperature was measured at 118.1 degrees Fahrenheit which was in compliance with Title 22 regulation.

Smoke detectors and carbon monoxide detectors are operable. Medications are centrally stored and locked.

(-Continued in LIC 809C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PACENCIA HOME
FACILITY NUMBER: 198600534
VISIT DATE: 11/22/2022
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Medications are properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguisher is fully charged and last service was on 10/28/2022. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. The front yard is well maintained. No pools or large bodies of water at the facility. Passageways are free of obstruction. Last disaster drill was conducted on 10/28/22.

No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report was discussed and provided to facility director, Eileen Vazuez Correos, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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