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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601376
Report Date: 03/15/2023
Date Signed: 03/15/2023 04:17:48 PM

Document Has Been Signed on 03/15/2023 04:17 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ARRIOLA FAMILY HOMEFACILITY NUMBER:
198601376
ADMINISTRATOR:LORENZO ARRIOLAFACILITY TYPE:
735
ADDRESS:1307 S. EVARG AVETELEPHONE:
(310) 537-3925
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 6CENSUS: 4DATE:
03/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Arriola TIME COMPLETED:
04:30 PM
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On 3/15/23, Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA conducted Covid-19 screening and there was no covid cases. LPA met with Administrator Lorenzo and staff Blanca Arriola, and explained the purpose of today’s visit. This facility is licensed to serve (6) Developmentally Disabled Adults ages 18 and over cleared for (6) bedridden clients. The home is a level 3 and is vendorized with the South Central Los Angeles Regional Center. Currently, the home has (4) non-ambulatory clients. The home is a two-story structure.

The LPA toured the property with Mr. Arriola and inspected the inside/outside facility grounds. This home consists of (3) client bedrooms (2) client bathrooms, living room, family room, kitchen, dining area, upstairs office, patio, garage used for storage and laundry area. There were no bodies of water or obstructions on the premises. Bedrooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured at 110 degrees Fahrenheit. A comfortable temperature was maintained in the Fahrenheit was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen and dining room was inspected and there was enough perishable and non-perishable food available and maintained properly. All cabinets were inspected. There was an additional refrigerator located in the garage and bottle waters. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable.

LIC 809-C is on the next pacg

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ARRIOLA FAMILY HOME
FACILITY NUMBER: 198601376
VISIT DATE: 03/15/2023
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Infection Control During the tour, LPA observed PPE supplies are readily available to staff, and an additional 30 day supply of PPE was observed stored in the garage. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed all required infection control postings throughout the facility.

Medications LPA reviewed medications for all 4 residents and matched them to the MARs. All medications are stored in a secured, locked cabinet located in the main bathroom.

Files LPA reviewed all 4 resident’s files. LPA reviewed 5 staff files and found they contained the required documentation. LPA interviewed 2 staff that were present during the visit. LPA was only able to interview 1 out of 3 clients due to client’s communication. LPA attempted interviews. LPA reviewed the facilities Surety Bond is through State Farm insurance. LPA reviewed all resident’s P&I.

Exit interview was conducted with Mr. Arriola and the copy of the report was given.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC809 (FAS) - (06/04)
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