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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602145
Report Date: 08/06/2022
Date Signed: 08/06/2022 05:36:19 PM

Document Has Been Signed on 08/06/2022 05:36 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DOWNEY AVENUE HOMEFACILITY NUMBER:
198602145
ADMINISTRATOR:RODRIGO MATEOFACILITY TYPE:
735
ADDRESS:6201 DOWNEY AVENUETELEPHONE:
(562) 210-5004
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 4CENSUS: 4DATE:
08/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Lilian Sestiaga & Sonny Untalan TIME COMPLETED:
11:59 AM
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
On 08/06/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with the house manager Lilian Sestiaga and faciltiy registered nurse Sonny Untalan. LPA explained the purpose of today’s visit. The facility is licensed to operate for non-ambulatory disability disable adults ages 18 through 59 years of age. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, two (2) common bathrooms, a living area, dining area, kitchen, and outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 106.9 degrees F. A comfortable temperature of 74 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The last fire drill was on 06/20/22 at 5;10 pm. The facility has a working landline telephone.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: DOWNEY AVENUE HOME
FACILITY NUMBER: 198602145
VISIT DATE: 08/06/2022
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
26
27
28
29
30
31
32
INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident vaccination records, test results, and daily temperature screening. The facility has an approved CCLD Mitigation Plan. The facility has submitted an Infection Control Plan for 2022 with CCLD.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Sonny Untalan .
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2