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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601593
Report Date: 03/30/2023
Date Signed: 04/12/2023 07:54:10 AM

Document Has Been Signed on 04/12/2023 07:54 AM - 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: 2DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria M. LopezTIME COMPLETED:
01:45 PM
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LPA Angelica Rea made an unannounced visit to PDM - Artesia. The purpose of today’s visit was to conduct the Required Inspection. On today’s visit LPA met with Administrator, Maria M. Lopez. The home has 2 consumers, both are non ambulatory and both have restricted health care condition(s). The facility conducted a fire drill on 3/1/23.

LPA Rea checked Client & Staff files, medications, staff fingerprint clearances, staff 1st aid certificates, consumer IPPs and inspected the home for hazards. During this visit, LPA inspected consumer bedrooms,two bathrooms, living room, dining room and kitchen, and laundry area. The consumer bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Bedrooms had plenty of dresser and closet space observed. Walls and floors were in good condition. Hallways were clean, clear, and free of debris. Toilets and water facets worked properly. Water temperature measured between 105 degrees F and 120 degrees F in kitchen and bathroom sinks. The fire extinguisher is fully charged and meets regulations.

Perishable food supply was checked and adequately stocked at time of visit. Smoke detectors were working properly, chemical compounds and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and in order. Outside grounds were toured and no bodies of water were observed.

No deficiencies cited. Exit Interview, and copy of report, provided to Ms. Lopez.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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