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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600567
Report Date: 07/06/2022
Date Signed: 07/06/2022 01:41:21 PM

Document Has Been Signed on 07/06/2022 01:41 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:SANTOS HOME-LAKEWOODFACILITY NUMBER:
198600567
ADMINISTRATOR:JAY S. SAMILINFACILITY TYPE:
735
ADDRESS:5719 OLIVA AVE.TELEPHONE:
(562) 531-7118
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 4DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator Marhona AmadoTIME COMPLETED:
01:55 PM
NARRATIVE
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On 7/6/22 at 11:10 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Ma Rhona Amado who assisted with the visit.

The facility is licensed to serve 4 clients between the age of 18 and 59 years old, ambulatory only. The facility is a single-story building in a residential area with a kitchen, dining room, Living room, 2 client bedrooms, 1 staff bedroom, 2 bathrooms, garage, and a backyard. The carbon monoxide/ smoke detectors were observed and tested in working condition. Fire extinguisher observed on the kitchen wall.

LPA discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

LPA observed all bedrooms with the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. The backyard is well maintained. The bathrooms had the required soap and paper towels. The hot water temperature measured between 112.1- 113.1 degrees F. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. LPA observed knife unlocked and located in dish storage next to the sink. S1 secured the knife during the visit. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. Medications reviewed for all residents and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6002076735 expire 3/16/2020. Administrator confirm manager sent in renewal 4/10/2022. LPA observed 30 days’ supply of PPE’s located in the garage.

Report continued on 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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: SANTOS HOME-LAKEWOOD
FACILITY NUMBER: 198600567
VISIT DATE: 07/06/2022
NARRATIVE
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Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted / Appeal Rights issued / A Copy of the Report Issued to administrator Ma Rhona Amado.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2022 01:41 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 07/06/2022 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTOS HOME-LAKEWOOD
FACILITY NUMBER: 198600567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064.3(d)
Administrator Recertification Requirements (d)

To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post marked on, or up to ninety (90) days before, the certification expiration date:

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed the administrator certificate on file expired 3/16/2020.
POC Due Date: 08/06/2022
Plan of Correction
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Administrtator stated documents was sent in on 4/10/22. LPA will search if administrator renewal application is pending on website. If LPA can not find the information on the website, Administrator will mail renewal information to Sacramento and LPA will check website by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2022 01:41 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 07/06/2022 at 01:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTOS HOME-LAKEWOOD
FACILITY NUMBER: 198600567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
Buildings and grounds

Disinfectants , cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisions, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed a knife unlocked and located ina dish holder next to kitche sink. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2022
Plan of Correction
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Administrator shall ensure that all sharp objects are stored in a locked area inaccessible to clients at all times. S1 immediately removed the sharp object and placed it in a locked cabinet. Deficiency cleared at the time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


LIC809 (FAS) - (06/04)
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