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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602364
Report Date: 10/24/2022
Date Signed: 10/24/2022 03:58:40 PM

Document Has Been Signed on 10/24/2022 03:58 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:CN HOME 2FACILITY NUMBER:
198602364
ADMINISTRATOR:MATHARU, ANITAFACILITY TYPE:
735
ADDRESS:14516 PIONEER BLVDTELEPHONE:
(310) 612-0978
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:House Lead- Margarita Aquino / Administrator Catherine LedesmaTIME COMPLETED:
04:00 PM
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On 10/24/22, Licensing Program Analyst (LPA) Ashley Calderon arrived at the facility to conduct an unannounced an annual required inspection. LPA Calderon met with House Lead Margarita Aquino and Caregiver Veronica Flores Santana and explained the purpose of todays visit.

LPA Calderon did a full inspection of the facility with Margarita. The facility is a single-story home with 4 bedrooms, 2 bathrooms, kitchen, living room, dining room, office room hallway with laundry machines, and the backyard with shaded area. During the inspection, LPA Calderon observed at the front door health screening and inspected the kitchen. Kitchen had locked cabinets that stored knives and chemicals and water measured at 113.9 degrees F. Sufficient non-perishable and perishable foods were observed. LPA Calderon inspected the bathrooms , bathroom #1 water read at 117.5 degrees Fahrenheit and bathroom #2 at 116.6 Fahrenheit degrees. LPA Calderon observed that the bathrooms were clean and maintained in safe, operable and sanitary conditions with equipment for handicapped individuals. LPA Calderon observed that at the facility there are personal hygiene items such as soap, toilet paper, toothpaste, paper towels and facility had PPE for about 60 days. LPA Calderon inspected and reviewed the medication, medications were stored and locked in the office room that is inaccessible to clients. LPA Calderon observed that the smoke detectors and carbon monoxide detectors which are combined, detectors were operational. LPA Calderon inspected the clients’ bedrooms. LPA Calderon observed that the bedrooms were clean, and the lights were operational and had good equipped furniture. LPA Calderon observed that there is one (1) unattached garage which is locked and inaccessible to clients. The garage is used for storage of chemicals, disinfectants, cleaning solutions, PPE, extra refrigerator which are not accessible to clients. Administrator certificate for Catherine Ledesma, Expires on 6/27/2023. Fire Drill last conducted on 10/18/22.

Continue on LIC 809C....
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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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: CN HOME 2
FACILITY NUMBER: 198602364
VISIT DATE: 10/24/2022
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During the inspection of the outside perimeter, LPA Calderon observed all passageways were free of obstruction and no large bodies of water observed. At 2:00pm Administrator - Catherine Ledesma came to the above home and LPA discussed the observations and spoke to Ledesma about employee S1 needing to be associated in Guardian. LPA Calderon accessed Ledesma with Guardian web page. Employee S1 is cleared, LPA did a employee file review on S1. At 3:40 pm LPA Calderon did the Inspection Tool-Infection Control Domain with Ledesma.

Based on the observations made during this annual inspection conducted, per Title 22 of the California Code of Regulations, no deficiencies were issued. An exit interview was conducted and a copy of this report was provided to Catherne Ledesma.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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