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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601369
Report Date: 08/04/2022
Date Signed: 08/04/2022 02:03:07 PM

Document Has Been Signed on 08/04/2022 02:03 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:MORALES FAMILY HOMEFACILITY NUMBER:
198601369
ADMINISTRATOR:ERNEST LUNAFACILITY TYPE:
735
ADDRESS:1821 PIERCE PLACETELEPHONE:
(626) 573-9126
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 4CENSUS: 3DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Ernest Luna, AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control domain. LPA met with Ernest Luna, the Administrator, and explained the purpose of the visit. The facility is licensed for 4 developmentally disabled adults. There are currently 3 adults residing in the home and were placed by the Eastern Los Angeles Regional Center.

The facility is a one-story home with 3 bedrooms (2 client bedrooms and 1 staff bedroom), 2 bathrooms (1 for client use and the other for staff), living room, dining room, kitchen, 2 activity rooms, and family room. There is an additional room set aside as an isolation room when needed. There are no pools or bodies of water at the home. Staff are continuing to document the temperature of clients, staff, and visitors. The facility are allowing visitation either inside or out. The facility has sufficient supplies of face masks, gloves, gowns, and hand sanitizers. The smoke detector and carbon monoxide detector were tested and operable. COVID-19 signage are posted at the door and throughout the home. There are sufficient food supplies of 2 day perishable and a week of nonperishable items. The cleaning products and knives are locked. They have extra supplies of soap, paper towels, and personal hygiene in storage. LPA reviewed all 3 medications and they are being administered as prescribed.

Per the Administrator, they are continuing to follow the mitigation plan. They have a plan to obtain backup staffing if there is a shortage. The staff are constantly cleaning and disinfecting the home. Both the Administrator and staff were wearing face masks.

LPA provided a technical assistance on the N95 respirator fit testing.

An exit interview was conducted. A copy of this report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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