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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601998
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:40:07 PM

Document Has Been Signed on 09/30/2024 02:40 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:NEW LIFE HOME B&CFACILITY NUMBER:
198601998
ADMINISTRATOR/
DIRECTOR:		ANDAYA, VERONICA KARENFACILITY TYPE:
735
ADDRESS:21139 S. ADRIATIC AVE.TELEPHONE:
(714) 740-1794
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 4CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:56 AM
MET WITH:Gian Yucon, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On September 30, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Gian Yucon, House manager and subsequently, Veronica Karen Andaya /Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (4) ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59. Currently, the home has (4) clients. The clients are from: Harbor Regional Center. (1) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices.

Structure The The one story residential home consists of (3) resident bedrooms, (2) resident bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs and shade.

Physical Plant LPA and Veronica Andaya toured the facility inside and outside. LPA observed there were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. LPA observed that facility had required postings: ombudsman poster, see something say something poster, emergency numbers, clients rights, Admin certificate, facility sketch, disaster plan, menu, insurance information.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: NEW LIFE HOME B&C
FACILITY NUMBER: 198601998
VISIT DATE: 09/30/2024
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Bedrooms LPA inspected all (4) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, nightstands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the client's bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. The water temperature measured 107-degrees Fahrenheit. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations. Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets.

Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, washer dryer (located in detached garage), refrigerator. LPA observed an ample supply of cutlery, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked under the sick cabinet and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. Cleaning products and toxins were secured in a cabinet that is inaccessible to clients.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: NEW LIFE HOME B&C
FACILITY NUMBER: 198601998
VISIT DATE: 09/30/2024
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Common Rooms In the living room, LPA observed adequate seating for clients in care: Sofa, love seat, visit sign in area, and TV. In the dining room, LPA observed a four seated dinning table and space designated for office use: desk, office chair, locked file cabinet, lanline phone and printer.

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed ( 2 ) fully charged fire extinguisher mounted on the wall, last serviced on 03/24/2024. The last emergency drill was conducted on 09/13/2024. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, gauze, disinfectant wipes, band aids and a manual. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises. Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked closet that is inaccessible to clients in care. Files LPA reviewed ( 4 ) client files and found (4) out of (4) the contained all the necessary documentation: Medical Assessment, TB Needs/services plan, consent forms, Clients Rights. LPA reviewed ( 4 ) staff files and found (4) out of (4) contained the required documentation, certification, and training. Liability Insurance expires on 01/19/2025. Licensing fee are current.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper towels, cleaning, and disinfecting supplies were observed.

There were no deficiencies cited during today’s visit.

An exit interview was conducted with Veronica Andya and a copy of this report was provided.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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