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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600534
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:31:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/14/2024 02:31 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PACENCIA HOMEFACILITY NUMBER:
198600534
ADMINISTRATOR/
DIRECTOR:
EILEEN CORREOSFACILITY TYPE:
735
ADDRESS:20507 HARVEST AVENUETELEPHONE:
(562) 221-9815
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Nathalia Vasquez AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Celia Tuazom at approximately 12:15 PM and explained reason for visit. Administrator Nathalia Vazquez arrived shortly.

The facility is to serve four (4) ambulatory developmentally disabled adults, age 18 through 59 years old. All current clients were placed by Harbor Regional Center. This is a single-story home located at a residential neighborhood which consists of a living room, kitchen, dining room, family room, office area, two (2) bathrooms, four (4) bedrooms, and back yard with covered patio and detached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the dining room and is properly operating. The facility has two (2) fully charged fire extinguishers which are kept in hallway and office. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen and closet in dining room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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: PACENCIA HOME
FACILITY NUMBER: 198600534
VISIT DATE: 11/14/2024
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in October of 2024. Infectious control plan and emergency disaster plan will be emailed to LPA.One (1) staff and (1) client was interviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

No deficiency was observed during today’s visit. Exit interview was conducted with Administrator and a copy of report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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