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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600674
Report Date: 10/07/2022
Date Signed: 10/07/2022 05:30:17 PM

Document Has Been Signed on 10/07/2022 05:30 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
GREATER LA AC/SC, 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:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Josephine CateTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Residential Technical Support Josephine Cate and explained the purpose of today's visit.

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.

The facility consists of four (4) client bedrooms (1 bedroom is designated as a staff bedroom), two bathrooms, 1 half bathroom, living room, Kitchen, Dining area, laundry room and a patio with chairs. Facility also has a detached garage that is used for storage.


The following were observed/inspected:
  • COVID-19 Infection Control Practices were observed at the entrance of this facility and throughout the facility.
  • Per Residential Technical Support all clients have both COVID vaccines and boosters.
  • Per Residential Technical Support all staff have both COVID vaccines and have the booster.
  • Bathrooms have hand soap and paper towels. Hand washing signs were observed inside both bathrooms.
  • PPE supplies observed. Additional PPE supplies are stored inside the garage.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supply is stored inside the garage.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CASA DE ADORA
FACILITY NUMBER: 198600674
VISIT DATE: 10/07/2022
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  • Staff responsible for direct care and supervision were wearing masks.
  • Clients were socially distanced according to local public health guidelines.
  • Clients are able to use their individual private rooms as designated isolation room a COVID-19 positive case should arise.
  • HIgh touch surfaces are being disinfected once a day.
  • Hand Sanitizer: Available throughout the facility for client use.
  • The clients and staff's temperature's are checked and logged daily.
  • Staff and clients are tested weekly and as needed if they are exhibiting or showing any symptoms.
  • Medication reviewed for (4) Clients (Client #1 through Client #4). 30 day supply of medication for clients.


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

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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