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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602174
Report Date: 08/12/2024
Date Signed: 08/12/2024 02:04:26 PM


Document Has Been Signed on 08/12/2024 02:04 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:ALLEN'S PALM COVE CERRITOSFACILITY NUMBER:
198602174
ADMINISTRATOR:DIMAANO, EUPHROSYNEFACILITY TYPE:
740
ADDRESS:18714 KINGS ROW AVETELEPHONE:
(562) 866-3585
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Peter Nora TIME COMPLETED:
02:19 PM
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On 8/12/24 at 12:00 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Allen Palm Cove. Upon arrival LPA was greeted by the Administrator, Euphrosyne Dimaano and Peter Nora. This home is licensed to serve age range 60 and over. Approved for 6 Non-ambulatory. There were (4) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 7/24/24. The Administrator Certificate expires on 2/14/2026 #7009404740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (4) resident files, medications, and medication administration records for (4) residents.

This home contains 4 bedrooms, 2 bathrooms, 2 living room, kitchen, 2 dining room, office space, and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 112.4*F-116.0*F. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in kitchen and garage fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The knives were secured and locked in a draw next to the stove. The cleaning agents and toxins are locked underneath kitchen sink. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALLEN'S PALM COVE CERRITOS
FACILITY NUMBER: 198602174
VISIT DATE: 08/12/2024
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for resident use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the residents.

Exit interview conducted with Euphrosyne Dimaano and Peter Nora, Administrator, a copy of this report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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