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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601521
Report Date: 06/17/2022
Date Signed: 06/17/2022 02:30:52 PM

Document Has Been Signed on 06/17/2022 02:30 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SIESTA CARE HOMEFACILITY NUMBER:
198601521
ADMINISTRATOR:RHEA ORTIZ-LUISFACILITY TYPE:
735
ADDRESS:335 S. SIESTA AVETELEPHONE:
(626) 333-1923
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 4DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Staff Adelaida GrafilTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an annual required visit. LPA met with staff Adelaida Grafil and explained the reason for the visit. Shortly after House Manager Leilani Telebrico arrived who assisted with the visit LPA used the infection control tool to evaluate the facility. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and client and staff records. Facility has submitted a mitigation plan. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.
This is a single story home located in a residential neighborhood. It consists of the following: 4 client bedrooms, 2 live-in staff rooms, 1 full client bathroom, and 1 1/2 client bathroom, 1 full staff bathroom, living/dining room area, kitchen, laundry area in the garage, garage closet room, backyard, and front yard with patio furniture. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Linens and personal hygiene supplies are stored in hallway closet.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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: SIESTA CARE HOME
FACILITY NUMBER: 198601521
VISIT DATE: 06/17/2022
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The bathrooms are clean and have the required grab bars and non-skid mat. The water temperature was tested 115.8 degrees which is within the required 105 - 120 degrees. Facility has sufficient perishable and non-perishable food. All the appliances in the kitchen are clean and working properly. Sharps and cleaning supplies were stored in a locked room that is attached to the garage and inaccessible to clients. The common areas such as living room, dining room are clean and have the required furniture.

LPA observed the centrally stored medication area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The carbon monoxide detectors were working properly, fire extinguishers were fully charged and operational.

LPA reviewed resident files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented and stored properly.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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