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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601959
Report Date: 07/28/2023
Date Signed: 07/28/2023 01:04:53 PM


Document Has Been Signed on 07/28/2023 01:04 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MOM & DAD'S HOUSEFACILITY NUMBER:
198601959
ADMINISTRATOR:IVONNE A. MEADERFACILITY TYPE:
740
ADDRESS:4340 CONQUISTA AVE.TELEPHONE:
(562) 627-0390
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY:6CENSUS: 6DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Ivonne Meader - AdministratorTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Ivonne Meader (Administrator) and explained the reason for the visit. The facility is licensed to serve six non-ambulatory residents ages 60 years and above and approved for four hospice waivers. Facility is operating within the scope of it's license.

A tour of the single-story facility included: living room, family room, kitchen, dining area, 5 resident bedrooms, 2 bathrooms, front yard, backyard and attached garage. LPA and Ivonne toured the facility and the following was observed: Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 116.7 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen in each resident bedroom’s closet and clean towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There are two carbon monoxides in the hallways and are properly operating. There is a fire extinguisher in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps, cleaning supplies and toxins are kept locked in a kitchen cabinet and are inaccessible to residents. First Aid kit was fully stocked with current manual and it is kept in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water at the facility. Passageways and exits are free of obstruction. The facility has a video camera monitor system in all common areas and hallway. All residents signed the video camera monitor system plan of operation and there are signs stating "security cameras in use". Residents medication are centrally stored in a locked cabinet in the dining area. Residents and staff files are centrally stored in the garage.
(Continued to LIC 809-C)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOM & DAD'S HOUSE
FACILITY NUMBER: 198601959
VISIT DATE: 07/28/2023
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LPA reviewed medication for all 6 of the residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 6 residents and 5 staff. LPA interviewed 2 residents and 2 staff. LPA observed administrator certificate for Ivonne Meader – 6032304740 with an expiration date of 08/19/2024.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report were provided.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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