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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601593
Report Date: 02/23/2022
Date Signed: 02/23/2022 04:39:03 PM

Document Has Been Signed on 02/23/2022 04:39 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:PDM - ARTESIAFACILITY NUMBER:
198601593
ADMINISTRATOR:MARIA M. LOPEZFACILITY TYPE:
735
ADDRESS:11419 176TH STREETTELEPHONE:
(562) 202-9281
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 3CENSUS: 1DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary GonzalesTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Administrator Mary Gonzales and the purpose of today’s visit was explained.

The facility is licensed to serve (3) Developmentally Disabled clients between the ages of 18-59 and is approved for three (3) non-ambulatory clients. Currently, there is one (1) clients in placement, who was hospitalized on 2/22/22. There are no clients who have a restricted health care condition.

LPA and Administrator Mary Gonzales toured the entire facility inside and out. The facility is a single story home located in a residential neighborhood and consists of living/ dining/ office room, kitchen, family room, laundry room, (3) client bedrooms, (2) bathrooms, backyard with shaded seating for clients, and an attached garage/ storage area.

Physical plant inside and outside is in good repair. Client rooms were checked and observed to have the required furniture for comfort and safety such as bed frames, dressers, lamps and chairs and all had sufficient lighting. Clients beds have the required linens which were in good condition at the time of the visit. Client bedrooms had sufficient closet/ storage space. Activity and game supplies were in stock. Adequate supply of linen stored in hall cabinet with additional towels and blankets. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Showers were free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients.

Report continues on LIC809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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: PDM - ARTESIA
FACILITY NUMBER: 198601593
VISIT DATE: 02/23/2022
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Water temperature properly measured at 110F*. Facility temperature was comfortable. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients located in a kitchen cabinet. Hazardous toxins and/or items are inaccessible to clients, fire extinguishers are fully charged. Food supply was observed to contain a (2) day supply of perishables and a (7) day supply of non-perishables that met title 22 guidelines. There was an adequate supply of dishware, utensils and cooking equipment and appliances were in working order. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

Washing machine and dryer are located in a laundry room next to the facility kitchen.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
  • Clients are able to use their own room as an isolation room if a COVID-19 positive case should arise.
  • 30 day supply of medication for clients
  • Facility has an adequate amount of PPE and facility has enough PPE for 30 days.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Hand Sanitizer: Available throughout the facility for client use.
  • The clients temperature's are checked and logged every four hours.
  • Staff temperatures are checked and logged every four hours and upon entering and finishing their shift.
  • Staff and clients are tested bi - weekly for COVID-19 (Surveillance testing)

Exit interview conducted, a copy of this report was provided to Administrator Mary Gonzales.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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