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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602365
Report Date: 09/30/2024
Date Signed: 10/01/2024 09:15:25 AM

Document Has Been Signed on 10/01/2024 09:15 AM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CN HOME 3FACILITY NUMBER:
198602365
ADMINISTRATOR/
DIRECTOR:		MANBIR SONDFACILITY TYPE:
735
ADDRESS:1511 W 219TH STREETTELEPHONE:
(310) 612-0978
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Hilaria Jimenez and Glory Callejas TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with staff member Hilaria Jimenez and Administrator Glory Callejas arrived later. LPA explained the purpose of today's Annual Inspection. LPA verified that the facility had approved mitigation and infection control plan reports. There are currently four (4), Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Food Service, Client Records-Incident Reports, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

Staff member Hilaria Jimenez and LPA Bunker toured the facility. The facility is a single-story home located in a residential neighborhood with, a living room, dining area, kitchen, 4 bedrooms, 3 bathrooms, office, laundry room, and an indoor/outdoor activity area—a shaded area with outdoor patio furniture, table, and seating chairs. Bedrooms #1-4 are designated as the client's bedrooms.

During the tour, LPA Bunker observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed.
See continued LIC809-C page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CN HOME 3
FACILITY NUMBER: 198602365
VISIT DATE: 09/30/2024
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Continued LIC 809-C page 2

Documents are displayed in the facility hallway, as well as on the office wall and cabinets. The following Title 22 Regulated areas were audited and found to be in compliance: The facility telephones are working. Bedrooms: All bedrooms meet the required standards for furniture, safety, privacy, and comfort. The facility has an adequate linen supply. Bathrooms: The bathrooms are clean and operational, and provide necessary personal accommodations with non-skid surface mats ensuring safety and privacy. Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of the food service revealed an ample supply of perishable and nonperishable food, stored appropriately.
Medication Storage and Management: Medications are centrally stored in a locked cabinet in the kitchen with up-to-date records, ensuring proper storage and documentation. Common Areas: The Living room, dining room, and common areas are well-maintained, free of potential hazards, and meet the cleanliness standards necessary for the safety and well-being of residents. Safety Equipment and Measures: The facility is equipped with a fully stocked first aid kit with manual, functional smoke and carbon monoxide detectors, and properly charged fire extinguishers. The hot water temperature is measured at 116 degrees and is maintained within the standard range of 105-120 degrees Fahrenheit. Emergency Preparedness: All exit doors are in compliance, the client's bedroom windows are equipped with sliding window locks without thumbscrews, and the facility conducted a fire drill on September 18, 2024. Environmental Safety: The yard is free from debris and hazards, trash cans are covered, and no firearms or bodies of water are present on the premises. Hazardous items are kept inaccessible to clients. Staff Training: Staff members have received training on reporting dependent adult and elder abuse. Administrative Compliance: The Administrator has successfully completed the required training, and their Administrator Certificate is current. The Administrator is awaiting for the physical certificate to be mailed.

LPA Bunker provided Administrator Glory Callejas with a copy of the facility evaluation reports.

There were no deficiencies cited.

Exit interview conducted
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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