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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602394
Report Date: 09/29/2021
Date Signed: 09/29/2021 01:18:17 PM

Document Has Been Signed on 09/29/2021 01:18 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:DOWNEY HOMEFACILITY NUMBER:
198602394
ADMINISTRATOR:MILIAN, GURITHFACILITY TYPE:
735
ADDRESS:11403 HORTON AVENUETELEPHONE:
(562) 682-2417
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 4CENSUS: 4DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Rodriguez (House Manager)TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Maria Rodriguez (House Manager) and explained the purpose of the visit. The facility is licensed to serve age range 18 through 59. 4 ambulatory.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, dining room, kitchen, pantry, laundry room, tv room, office, 3 client bedrooms, 3 bathrooms and a detached garage.

During today's visit, LPA observed the following: LPA was allowed to enter the facility to conduct the inspection. The bathrooms are clean and operational. Clients bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested in bathroom #1 and measured within Title 22 Regulation guidelines. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to residents. The last Fire/Emergency Drill was conducted on 06/02/21. LPA reviewed staff files, and client medications. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible. Staff have a criminal record clearance. The Administrator's certificate is current. Smoke detectors/Carbon monoxide detectors are operable. The fire extinguisher was observed in the laundry room and was fully charged. The first-aid kit is fully stocked w/First-aid Manual. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. There is no pool, large bodies of water or weapons on the premises.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Maria Rodriguez.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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