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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600918
Report Date: 01/16/2025
Date Signed: 01/16/2025 11:18:07 AM

Document Has Been Signed on 01/16/2025 11:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ROBILYN GUEST HOME, INC.#3FACILITY NUMBER:
198600918
ADMINISTRATOR/
DIRECTOR:		CARLOS CUNANANFACILITY TYPE:
735
ADDRESS:10909 HAYFORD STTELEPHONE:
(562) 868-0464
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Carlos Cunanan/S1TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPAs) Elizabeth Irra conducted the required annual inspection. LPA met with Carlos Cunanan (S-1) and discussed the purpose of today’s visit.

This home consists of (4) bedrooms, (2) bathrooms, (1) office, kitchen, dining area, living room, laundry area (outside) and unattached garage. Harbor Regional Center provides case management services to all clients from this home. Fire Department cleared/approved (2) ambulatory and (2) non-ambulatory clients.

LPA utilized the Compliance and Regulatory (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control plan in place.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detector (located in the hallway near bedrooms) tested and operable. Fire extinguisher was last serviced on 11/23/24 (located in the kitchen and hallway near the bedrooms). Last fire drill was conducted on 11/05/24. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Hot water temperature measured at 112.0* in the hallway bathroom (near bedrooms) and 115.3* in the bathroom located near the kitchen.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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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: ROBILYN GUEST HOME, INC.#3
FACILITY NUMBER: 198600918
VISIT DATE: 01/16/2025
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Personnel Records-Training: LPA reviewed staff files for Staff #1 (S-1) and Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis.

Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and locked (inside the office). Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per S-1, there are (0) clients with a restrictive health plan, (0) clients utilizing postural supports and (0) clients with prohibited health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan in place.

Exit interview, appeals rights and a copy of this report was provided to Carlos Cunanan (S-1).
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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