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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600581
Report Date: 02/28/2022
Date Signed: 03/30/2022 11:27:14 AM

Document Has Been Signed on 03/30/2022 11:27 AM - 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: 36DATE:
02/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nicholas Novella TIME COMPLETED:
01:15 PM
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LPA Nicol Wesley conducted an unannounced case management visit at the facility and met with Facility Manager Nicholas Novella. The purpose of todays visit is to conduct a health and safety inspection, and to gather information regarding the SIR/UIR(unusual incident report) dated 02/14/22, for an incident involving client #1 that occurred on 02/10/22.

During the visit LPA Wesley reviewed client #1's file and requested supportive documents(IPP, MAR, ID page, and current Physicians reports). LPA also reviewed the file for Staff #1 and requested copies of specific documents. LPA Wesley did not conduct any interviews with Direct Support Professionals or the clients living in the facility.

LPA Wesley did not observe there to be any immediate health and safety concerns.

A copy of this report was provided during the exit interview.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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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