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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602872
Report Date: 11/09/2024
Date Signed: 11/09/2024 12:59:57 PM

Document Has Been Signed on 11/09/2024 12:59 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GREAT PLACE HOME CAREFACILITY NUMBER:
198602872
ADMINISTRATOR/
DIRECTOR:
SARMIENTO, BERNADETTEFACILITY TYPE:
740
ADDRESS:1556 238TH STREETTELEPHONE:
(310) 891-3349
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:54 AM
MET WITH:Administrator Coty CabraTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 11/09/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Administrator Coty Cabral. Facility is licensed to serve residents age range 60 and over, six non- ambulatory residents of which, one may be bedridden and approved hospice waiver for two residents. During this visit, there were zero hospice residents. This is a single-story home consisting of four resident bedrooms, one staff bedroom, one common bathroom, one ensuite bathroom (bedroom#5), living room, kitchen with dining area, garage, and a shaded outdoor patio. The facility is clean, sanitary, and in good repair.

The Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Continue to LIC809-C.

Ulysses CoronelTELEPHONE: (323) -40-7397
Regina CloydTELEPHONE: 323-981-7155
DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GREAT PLACE HOME CARE
FACILITY NUMBER: 198602872
VISIT DATE: 11/09/2024
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced October 3, 2024 was observed in the kitchen area. Another fire extinguisher was observed in the hallway. Administrator tested the carbon monoxide and smoke detectors in the house. Device were functional and interconnected.

Five staff records were reviewed, and five out of five staff records had current first aid certificates and required criminal record clearances or criminal record exemptions.

Five resident records were reviewed, and five out of five resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed.

No deficiencies are being cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Administrator Coty Cabral.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
LIC809 (FAS) - (06/04)
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