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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602365
Report Date: 09/17/2022
Date Signed: 09/17/2022 02:38:50 PM

Document Has Been Signed on 09/17/2022 02:38 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
MONTEREY PARK, CA 91754
FACILITY NAME:CN HOME 3FACILITY NUMBER:
198602365
ADMINISTRATOR:MANBIR SONDFACILITY TYPE:
735
ADDRESS:1511 W 219TH STREETTELEPHONE:
(310) 612-0978
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 4DATE:
09/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:FERNANDO CALLEJASTIME COMPLETED:
12:30 PM
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On 9/17/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit. Upon arrival, LPA Montoya called the facility, spoke with Melinda Black and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with Staff Renato Panay and Staff Sheila Soyangco. Staff Luis Pasillas arrived prior to his 10:00 am shift to relieve Staff Panay. Administrator Fernando Callejas and House Manager Hilaria Jimenez arrived later and joined the visit. LPA explained the purpose of today’s visit.

The facility is a single story building licensed to serve four (4) non-ambulatory clients ages 18-59. The facility consists of four (4) bedrooms, three (3) bathrooms, kitchen, dining area, living room, laundry room, and a small enclosed office space. This facility has an alarm system. LPA observed four residents present during the visit.

LPA Montoya toured and inside and outside grounds of the facility with Staff Soyangco and later Callejas took over. LPA observed 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, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 117.6 degree Fahrenheit. A comfortable temperature 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 residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (1) fire extinguisher that was charged and last serviced on 3/1/2022, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 8/24/2022. A working telephone (424) 558-3929 remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2022
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CN HOME 3
FACILITY NUMBER: 198602365
VISIT DATE: 09/17/2022
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

A technical assistance was provided. No deficiency cited.

An exit interview was conducted with Administrator Fernando Callejas, and a hard copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2022
LIC809 (FAS) - (06/04)
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