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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601593
Report Date: 02/27/2024
Date Signed: 03/07/2024 12:36:38 PM

Document Has Been Signed on 03/07/2024 12:36 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: 2DATE:
02/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Mirafy Lopez TIME COMPLETED:
11:11 AM
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On 2/27/24 at 8:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to PDM Artesia. Upon arrival LPA was greeted by Administrator Archie Lopez. Administrator Mirafy Lopez arrived at 8:50. This home is licensed to serve three (3) Developmentally Disabled Adults, (3) non-Ambulatory adults ages 18 through 59. The level for the home is 4I and the vendor is Harbor Regional Center. There were (2) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 1/10/24. The last fire inspection was conducted on 03/06/23. The Administrator Certificate expires on 5/10/2024 #6056119735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (2) client files, medications, and medication administration records for (2) clients and P&I.

This home contains 3 bedrooms, 2 bathrooms, living room, office space, kitchen, dining room, laundry room, activity room, and an attached garage. LPA toured the physical plant with the Administrator. and observed all (3) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 118.4*F-119.3*F. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in the office space and attached garage fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked in kitchen cabinet. The cleaning agents and toxins was also locked in a kitchen cabinet. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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: 02/27/2024
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The outdoor grounds were toured and inspected and observed to have a shed that contained storage supplies. the patio was well maintained with a shaded seating area accessible for client use. The garage contained cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, PPE’s, activity supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The activity room contained playing cards, board games and activity supplies available to the clients.

The office area contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

Exit interview conducted with Mirafy Lopez, Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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