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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601622
Report Date: 07/25/2022
Date Signed: 07/25/2022 06:13:16 PM

Document Has Been Signed on 07/25/2022 06:13 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:FARIMAN VAN ZANT HOMEFACILITY NUMBER:
198601622
ADMINISTRATOR:JACLYN VAN ZANTFACILITY TYPE:
735
ADDRESS:19209 FARIMAN DRIVETELEPHONE:
(310) 763-9269
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 3DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Gabriela Alpizarchaves - AdministratorTIME COMPLETED:
03:30 PM
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On 07/25/2022, 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 Administrator Gabriela Alpizarchaves (Quintero) and explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory developmentally disabled adults 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, one (1) staff room, two (2) bathrooms, living area, a dining area and kitchen. There is an outside patio area with an umbrella in the middle of the courtyard with ample seating. The backyard is used for outdoor activities. The laundry area is in a locked room located within the recreation room which is the garage. No cars are stored in the garage.

LPA and Administrator 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 met Title 22 standards in the bathrooms and kitchen sink and measured 118.5 F to 120.0 F. A comfortable temperature was maintained in the facility.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FARIMAN VAN ZANT HOME
FACILITY NUMBER: 198601622
VISIT DATE: 07/25/2022
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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 and maintained properly. There is one (1) fire extinguisher fully charge located near the kitchen wall. 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 kitchen area above the microwave oven.

There was one (1) technical advisory issued during the visit. See 9102-TA page.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Administrator Gabriela Alpizarchaves (Quintero).
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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