198600581-8-1-2025-28-AS-MGFS-DK5SXB-20250801141539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600581
Report Date: 08/01/2025
Date Signed: 08/01/2025 02:16:03 PM

Document Has Been Signed on 08/01/2025 02:16 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:	HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME		FACILITY NUMBER:	198600581
ADMINISTRATOR/ DIRECTOR:	VIDA ANDRADE		FACILITY TYPE:	735
ADDRESS:	11401 BLOOMFIELD, BLDG.305-307		TELEPHONE:	(562) 207-9660
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 38		CENSUS: 34	DATE:	08/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Rosario Navarrete - Program Manager		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Rosario Navarrete Program Manager and explained the reason for the visit. Administrator arrived shortly after. This facility is licensed to served 38 ambulatory only mentally disabled adults ages 18-59 years old. The facility is located inside a Hospital's property and it is a two story building which is compose of several client bedrooms, offices, a commercial kitchen, a dining room area, an activity/rest area, 9 client bathrooms, 1 staff bathroom, a medication room. The following CARE tool domains were reviewed during this visit: Infection Control: Facility maintains an infection control plan and will email a copy to the department. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility. Physical Plant & Environmental Safety: LPA toured the facility with Rosario Navarrete and observed the facility is in good repair indoors and outdoors. Activity room/dining room has sufficient seating area, it's clean and in good repair. Each client bedroom has sufficient lighting, the required furniture and bedding supplies. Nine bathrooms were observed clean and in good repair. Water temperature was tested between 92.1-128.1 degrees F., which is not within the required 105-120 degrees F. Carbon Monoxide/Smoke detectors were observed in each client room and a fire sprinkler system was observed throughout the building. Laundry area was observed clean and in good repair, detergent is provided to the clients as needed. Kitchen was observed clean, in good repair. Passageways and exit areas were observed free of obstructions. No large bodies of water were observed. First aid kit and fire extinguishers were observed which were last checked on 10/15/24 (CONTINUED ON LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 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: 08/01/2025

NARRATIVE

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Building is a historical building and therefore, windows do not have window screens.
Operational Requirements: Facility has a fire clearance. The outside provides a gazebo area and large trees as shaded seating area for the clients.
Staffing: Sufficient staff were observed during the visit. Facility is not vendorizes through the Regional Center.
Personnel Records - Training: All staff records were available for review. Each staff has a criminal background clearance. Administrator certificate was observed for Vida Andrade #7002768735 exp. date: 12/09/25. TB/HIV training on file. Five staff files were reviewed which include health screenings, TB test clearance, personnel records, finger clearance, and training. Four staff was interviewed.
Client Rights - Information: Clients rights and other posters were observed posted in the main entry way. A device with internet access is available. No postural supports were observed.
Food Service: Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Two clients have a modified diet.
Client Records - Incident Reports: Client records were available for review. Files were reviewed for 5 clients, which included medical assessments, admission agreement, pre-appraisal, needs and care plan, and TB test. Client #2(C2) does not have a medical assessment on file. Four clients were interviewed.
Health-Related Services: Medications were observed centrally stored. A staff assist clients with medication and PRN medications. Staff have a current First Aid/CPR training on file and are responsible for contacting emergency services. Medication was reviewed for 5 clients.
Incidental Medical Services: There are no residents with health services needs.
Disaster Preparedness: Emergency Disaster Plan LIC610D (10/03) was observed and last reviewed on 9/12/23, which is not the current LIC 610D(12/21). Facility has an additional Emergency Disaster Procedures which do not meet the Care Tool regulation/health and safety code requirements. Last emergency drill was conducted on 7/17/28. Emergency food supplies were observed. Emergency evacuation chairs were not observed at the top or bottom of stairwells.

Deficiencies were noted on LIC 809D per Title 22 Regulations during this visit.

Exit interview was conducted with Vida Andrade Administrator and a copy of this report, LIC 809D and Technical violation/advisory were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2025 02:16 PM - It Cannot Be Edited

Created By: Mary G Flores On 08/01/2025 at 01:11 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: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME	FACILITY NUMBER: 198600581
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in water temperature was tested in bathroom #109 at 128.1, #212 at 92.1, #202 at 96.6, #226 at 122.7 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2025
	Plan of Correction
1 2 3 4	Maintenance Director adjusted water temperature at the time of the visit. Administrator will submit a 7 daily log of water temperature in the rooms listed and submit a copy to the department by 8/7/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025

LIC809 (FAS) - (06/04)

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