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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600674
Report Date: 11/16/2021
Date Signed: 11/30/2021 05:32:40 PM

Document Has Been Signed on 11/30/2021 05:32 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:CASA DE ADORAFACILITY NUMBER:
198600674
ADMINISTRATOR:COOK,CARLTON,HELEN&ISAACFACILITY TYPE:
735
ADDRESS:5486 EDGEWOOD PLACETELEPHONE:
(323) 935-1801
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 6CENSUS: 4DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Josephine CateTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Residential Technical Support Josephine Cate and the purpose of today’s visit was explained.

There are currently (4) clients in the facility. The facility is licensed to serve (4) developmentally disabled adults ages 18-59 years old and approved for (2) non-ambulatory clients. Facility is operating within the approved capacity.

LPA and Residential Technical Support Josephine Cate toured the entire facility inside and out. The facility is a single story structure located in a residential neighborhood. Facility consists of the following: living room, kitchen, dining room, four (4) bedrooms (1 bedroom is designated as a staff bedroom), two bathrooms, half bathroom, laundry room with patio and chairs. Bathrooms are clean and operational. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. The facility was at a comfortable temperature. All client rooms that were inspected had the required furniture for comfort and safety such as bed frames, dressers, lamps and chairs and all had sufficient lighting. Clients beds have the required linen and the linen was in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Ample supply of perishable and nonperishable food, hot water temperature measured at 110 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

Report continues on LIC809C)

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CASA DE ADORA
FACILITY NUMBER: 198600674
VISIT DATE: 11/16/2021
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The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
  • Clients are able to use a designated isolation room that will be used as isolation room if a COVID-19 positive case should arise.
  • 30 day supply of medication for clients
  • Facility has an adequate amount of PPE and facility has enough PPE for 30 days.
  • Clients were socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils etc).
  • Hand Sanitizer: Available throughout the facility for client use.
  • The clients temperature's are checked and logged once a day in the AM.
  • Staff and clients are tested weekly for COVID-19.


Exit interview conducted, a copy of this report was provided to Residential Technical Support Josephine Cate.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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