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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602255
Report Date: 09/28/2021
Date Signed: 09/28/2021 06:11:55 PM

Document Has Been Signed on 09/28/2021 06:11 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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - DOMINGUEZ HOMEFACILITY NUMBER:
198602255
ADMINISTRATOR:SIGNEY, RACHELFACILITY TYPE:
735
ADDRESS:214 E DOMINGUEZTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 3CENSUS: 3DATE:
09/28/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Claudio Rosas & Linda SmithTIME COMPLETED:
04:00 PM
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On 09/28/21 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at this facility and met with the Administrator Claudio Rosas and the Registered Nurse Linda Smith and explained the purpose of today’s visit is to conduct a plant inspection and health and safety check.

The Department had received verbal information on 09/21/21 for client #1 (C1). Details of the information brought concerns for (C1) and how his medications are being handled by this facility. LPA reviewed Medication Administrator Record (MARs) and (C1)'s service records. LPA interviewed Rosas and Smith regarding incidents 6/21/21 and 09/09/21. LPA was provided copies of pertinent information regarding (C1). Rosas states that further documents relating to (C1) will be provided by Jeri Miles the Area Director.

An exit interview was conducted, with the administrator Claudio Rosas. A copy of this report is provided by email.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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