<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602076
Report Date: 09/26/2023
Date Signed: 09/26/2023 12:00:04 PM

Document Has Been Signed on 09/26/2023 12:00 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: 35DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ellisset RamirezTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced annual visit at the facility which included the following domains:
Infection Control, Physical Plant and Environmental Safety, Operational Requirements, Staffing, Personnel Records- Training, Client records- Incident Reports, Client rights- Information, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.
LPA Trueman met with Administrator Ellisset Ramirez and explained the reason for the visit.

The facility is an Adult Day Program (ADP) licensed to serve 50 clients, of which 10 may be non-ambulatory, ages 18 and over. The program consists of: Resting Area, Television Room, Art Room, Dining Room, Kitchen, Computer Room and Waiting Room.
LPA toured the facility and the following was observed: There were 35 clients at the facility during the visit. The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. Disinfectants, cleaning solutions and poisons are inaccessible to clients and are locked. The restrooms were observed to be clean and have the required grab bars for non-ambulatory clients.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
All staff were cleared and associated.
The program maintains a comfortable temperature in each room/office.
The First Aid kit is kept and it is fully stocked with all required items including a current manual. Food is not prepared at this program and clients are able to bring their own food.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Medication is not administered at program.
5 staff files and 5 client files were reviewed.
Interviews were conducted with 4 Staff and 4 Client's.
No deficiencies. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1