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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600581
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:44:37 PM

Document Has Been Signed on 09/08/2023 03:44 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: 29DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH: Administrator Vida AndradeTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced annual required visit. LPA met with Administrator Vida Andrade and explained the reason of the visit. During today's inspection LPA used the CARE Inspection Tool to evaluate the facility. LPA observed the facility plant, reviewed clients' medications, observed food supply, interviewed clients and staff and reviewed clients and staff files.

The facility is a two story structure building licensed to serve: MENTALLY DISABLED ADULTS AGES 18 TO 59 YEARS OLD, AMBULATORY ONLY. LPA conducted a facility tour, inside and outside with Administrator VIDA ANDRADE. The facility includes: Community Lounge, Dining Room, Kitchen, Staff Lounge / Medication Room, Laundry Room, (4) offices, and approx. (10) storage rooms. The facility contains a total of 23 bedrooms, bathrooms upstairs and downstairs (including one for staff, kept locked). Bathrooms observed have running hot water, hot was temperature measured between 112.7 and 120 degrees F which is within the Title 22 regulation. LPA inspected random resident bedrooms: # 111, #123, #128, #209, #214 and #229. Each bedroom had required beds for each client, chairs, night stands, dressers and required bed linen and sufficient lighting and closet space. Facility has call systems in clients room. LPA observed extra linen and towels located on the 2nd floor. The refrigerator, freezer and the pantry in the kitchen have sufficient 2 days perishable and 7 days non-perishable food supply. All the appliances in the kitchen are working properly. The facility has a covered patio area for shade (Gazebo) used for outside activities. No large bodies of water observed. Pathways, hallways and stairs are free of obstructions. No elevator located in the facility.

LPA inspected the carbon monoxide detectors which were operable. Smoke detectors throughout the facility are hard wired through the Fire Department of Norwalk, and facility has a fire alarm pull systems in place. There are fire extinguishers throughout the facility and they are up-to-date, charged and serviced. Last Fire Drill conducted on: 9/01/2023.

Continuation on 9099-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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: 09/08/2023
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LPA reviewed reviewed (3) client medications and medication administration records. No deficiencies observed.

LPA reviewed (3) clients files to confirm proper documentation's were in place. LPA also reviewed (3) staff files to confirm proper documentation's were in place, tb and fingerprint clearances. No deficiencies were observed.

Facility uses infection control plan practices, bathrooms have sufficient soap, paper towels, and signs, PPE supplies observed. Zero covid cases at the time of visit.

Administrator Certificate Expires: 12/9/2023

No deficiencies were observed during the visit.

Exit interview conducted. A copy of the report was provided to the administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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