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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602076
Report Date: 05/04/2022
Date Signed: 05/04/2022 07:56:51 PM

Document Has Been Signed on 05/04/2022 07:56 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EMPOWER UNLIMITED POTENTIALFACILITY NUMBER:
198602076
ADMINISTRATOR:RAMIREZ, ELLISSETFACILITY TYPE:
775
ADDRESS:6713 SEVILLE AVETELEPHONE:
(323) 770-4440
CITY:HUNTINGTON PARKSTATE: CAZIP CODE:
90255
CAPACITY: 50CENSUS: 26DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ellisset RamirezTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Ellisset Ramirez and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Administrator Ellisset Ramirez today 05/04/2022 at 12:30 PM and the following was observed:
Facility contains : Resting Area, Television Room, Art Room, Dining Room, Kitchen, Computer Room and Waiting Room.
Required Annual inspection included Infection Control Domain and check of the food supply, medications and criminal clearance check.
Program does not provide food and doesn't administer medications.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Temperature checks are conducted.
Staff have been trained in hand washing.
Staff are sufficient with no shortages and there is a plan to replace workers if ill.
There are rooms available if isolation is needed.
Bathrooms have proper signage for hand washing. There are multiple stations for hand sanitizing.
Social distancing is implemented. Meal times are sanitized after each meal.
Facility has sufficient supply of PPE. Facility has a specific plan to ensure proper cleaning and disinfection of environmental surfaces and laundry; commonly touched surfaces are cleaned and disinfected at least once every shift . Plan when to notify medical provider if symptoms develop or COVID-19 exposure or when to call 911 for severe respiratory distress. Advisory Notice issued. Exit interview conducted.
Due to computer technical issues the facility representative signature was unable to be signed at time of visit.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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