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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600581
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:08:18 PM

Document Has Been Signed on 12/06/2022 02:08 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:HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOMEFACILITY NUMBER:
198600581
ADMINISTRATOR:VIDA ANDRADEFACILITY TYPE:
735
ADDRESS:11401 BLOOMFIELD, BLDG.305-307TELEPHONE:
(562) 207-9660
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 38CENSUS: 31DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Vida Andrade TIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with administrator Vida Andrade and Facility Manager Nicholars Novella and explained the reason of the visit LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients and staff files.

The facility is a two story structure building. The facility includes: Front Entrance, Community area, Dining Room, Kitchen, staff lounge, laundry room, admin office, staff office, storage rooms. there are 15 double occupancy and eight single occupant client bedrooms for a total of 23, 10 bathrooms of which six are located upstairs and four downstairs (including one for staff). LPA inspected Room#211, #204, #123 and #127 and each bedroom has two beds, two chairs, two night stands, two dressers and required bed linen and sufficient lighting and closet space. LPA also checked two bathrooms upstairs and two bathrooms downstairs and they are all clean, sanitary and in a good working condition. The hot water temperature tested in between four bathrooms were between 108.8 and 115.1 degrees F which is within the Title 22 regulation. The refrigerator, freezer and the pantry in the kitchen has sufficient 2 days perishable and 7 days non-perishable food supply. All the appliances in the kitchen are working properly. The common area such as community area has required furniture. The facility also has a covered patio area called Gazebo used for outside activities. LPA also inspected the carbon monoxide detectors throughout the facility and they are working properly. There are also fire extinguishers throughout the facility and they are up-to-dated.

LPA reviewed 3 Clients files to confirm emergency contact and they are all updated. LPA also reviewed three staff files to confirm health screenings and fingerprint clearances. They are all fully vaccinated. They are also fingerprint cleared and they have updated Health Screening in their personnel file. LPA also reviewed 3 clients medication and they are accurate and updated.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME
FACILITY NUMBER: 198600581
VISIT DATE: 12/06/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in the common area and facility is disinfected every 2 hours, bathrooms have sufficient soap, paper towels, and signs, PPE supplies are sufficient for more than 3 months.

No deficiencies were observed during the visit.

Exit interview conducted. A copy of the report was provided to the administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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