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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601989
Report Date: 08/23/2024
Date Signed: 08/23/2024 11:28:56 AM

Document Has Been Signed on 08/23/2024 11:28 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CL HOMEFACILITY NUMBER:
198601989
ADMINISTRATOR/
DIRECTOR:
MELISSA M. LOPEZFACILITY TYPE:
735
ADDRESS:9932 AHMANN AVENUETELEPHONE:
(562) 889-8327
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 4CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:Administrator Melissa Lopez TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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LPA Tyler Reyes conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Melissa Lopez and explained the reason for the visit.

LPA Reyes toured the facility inside and out, reviewed food supply, reviewed (4)staff files, (4)resident files, and reviewed (4)resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathroom is functioning and is clean. Showers also have non-skid materials. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors/carbon monoxide detectors located throughout the facility, tested and operational. Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. Medications are centrally stored and in their original containers. Toxins and knives are locked. LPA reviewed 4 residents' medications and they are being administered as prescribed by the physician. The facility has an Emergency Disaster Plan posted with contact numbers. Last Emergency Disaster Drill 7/25/24 and Administrator's certificate expires on 9/19/2024. LPA Reyes Interviewed (2) staff and no clients were available to be interviewed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Administrator Lopez.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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