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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601574
Report Date: 03/21/2022
Date Signed: 03/21/2022 05:52:07 PM

Document Has Been Signed on 03/21/2022 05:52 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CARTAGENA HOMEFACILITY NUMBER:
198601574
ADMINISTRATOR:VALERIE JACKSONFACILITY TYPE:
735
ADDRESS:1306 CARTAGENA STREETTELEPHONE:
(562) 988-8142
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 4CENSUS: 4DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Pearl LambTIME COMPLETED:
02:47 PM
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On 3/21/2022, Licensing Program Analyst (LPA) Ngozi Nwaokoro conducted an unannounced Required- 1 year visit, with emphasis on infection control and met with Administrator Pearl Lamb. The facility is licensed to serve four (4) non-ambulatory adults ages 18 to 59, with developmental disability.

LPA Nwaokoro and Administrator toured the entire facility which included: Living room, office area, kitchen, dining room, 4 resident bedrooms and 3 bathrooms(1 in bedroom #1 and bedroom #3), front yard, back yard contained a deck and area for shade, and a detached garage. Bedrooms contained the required linen and furnitures. Bathrooms are clean and operational, smoke detectors/carbon monoxide detectors are working and operational. Fire extinguishers are fully charged and located on the wall in the office area, and dining room area. The first aid kit with manual was observed to be in compliance. Hot water was checked, and water temperature measured at 114.9F. LPA observed the nonperishable and perishable supply of food to be in compliance. Medication and MAR logs are stored in a locked file cabinet in the office area. The back yard and outside shade area was observed. LPA also reviewed staff files and residents files .

There were no deficiencies cited during today’s visit.

A copy of the LIC 809 was given to the Administrator, Pearl Lamb during the exit interview.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Ngozi Nwaokoro
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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