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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601604
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:52:08 AM

Document Has Been Signed on 11/17/2022 11:52 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - 256TH HOMEFACILITY NUMBER:
198601604
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:1716 256TH STREETTELEPHONE:
(424) 263-4028
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 4CENSUS: 3DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Area Director - Ronald BautistaTIME COMPLETED:
12:30 PM
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On 11/17/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Direct Service Provider (DSP) Dulce Pacheco and was later joined by Area Director Ronald Bautista and explained the purpose of today’s visit. The facility is licensed to operate for four (4) developmentally disabled clients of between the ages of 18 through 59.


The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, two (2) bathrooms, a living area, a dining area and kitchen. There is an outside patio area with ample seating and an umbrella used for shade. The laundry area is a room with a door and locked cabinets. There is a detached garage used for storage only.


LPA and DSP toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 105.1 F and 107.6 F in the bathrooms and kitchen sink. A comfortable temperature was maintained in the facility.


Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - 256TH HOME
FACILITY NUMBER: 198601604
VISIT DATE: 11/17/2022
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are two (2) fire extinguishers fully charge located in the hallway near the front door and the back door. Smoke detectors and carbon monoxide were operable and in working condition. A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate.


During the visit, LPA observed the facility infection control practices. LPA observed hand sanitizer available and temperature taken upon entry to the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). There is a fully stocked first aid kit in the laundry area.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Ronald Bautista.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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