198600864-10-13-2022-28-AS-JBAE-CK6PX7-20221013114154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600864
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:42:16 AM

Document Has Been Signed on 10/13/2022 11:42 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:	NORWALK HOME		FACILITY NUMBER:	198600864
ADMINISTRATOR:	CHARMILEY VENTURA		FACILITY TYPE:	735
ADDRESS:	14813 CAMEO AVENUE		TELEPHONE:	(562) 404-2849
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 5		CENSUS: 4	DATE:	10/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Administrator Melanie Estepa		TIME COMPLETED:	11:56 AM

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On 10/13/22 at 09:33 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with staff lead and explained the reason for the visit. At 10:50 Administrator Melanie Estepa arrived and assisted with the rest of the visit.

The facility is licensed to serve 5 clients between the age of 18 and 59 years old, all of which shall be non- ambulatory. All the clients receive services from Harbor Regional Center. The facility is a single-story building in a residential area, with a kitchen, dining room, living room, 5 bedrooms, 1 staff bedroom, 3 bathrooms, garage, and a backyard with a detached shed. Fire extinguisher observed fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.

LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Report continued 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NORWALK HOME	FACILITY NUMBER: 198600864
	VISIT DATE: 10/13/2022

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Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials and grab bars. The hot water temperature measured at 109.2- 112.4 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in the garage. Infection control signs were observed throughout the facility. Medications reviewed for all clients and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6030475735 expire 04/03/2024. Last emergency disaster drill 9/30/22.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Administrator Melanie Estepa.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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