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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602875
Report Date: 05/16/2022
Date Signed: 05/16/2022 11:45:41 AM

Document Has Been Signed on 05/16/2022 11:45 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA BARBARAFACILITY NUMBER:
198602875
ADMINISTRATOR:HENRY A LARAFACILITY TYPE:
735
ADDRESS:3453 LIBERTY BOULEVARDTELEPHONE:
(562) 682-9667
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 4CENSUS: 4DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Henry Lara, AdministratorTIME COMPLETED:
12:00 PM
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On 5/16/22 at 10:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. LPA met with administrator Henry Lara and explained the purpose of the visit. LPA and administrator toured the facility together.

Facility is licensed to serve 4 clients between the ages 18-59. Approved for 4 ambulatory clients. Facility is serviced by South central/ Los Angeles Regional Center. The facility is a single-story building in a residential area, with a commercial kitchen, dining room, living room, 3 bedrooms, 2-bathroom, backyard with ample shaded area and a garage. Fire extinguisher observed in dining room fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.

LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, staff files, and resident medications.

Report continued on 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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: CASA BARBARA
FACILITY NUMBER: 198602875
VISIT DATE: 05/16/2022
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Bedrooms 1-3 have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. All sharps are locked and secured. Passageways and exits are free of obstruction. The front and backyard are well maintained. Bathrooms 1-2 are clean and have the required grab bars and skid matts. The hot water temperature measured at 120.2 degrees F for bathrooms 1-2. The facility temperature at the time of the visit was comfortable. There is sufficient lighting throughout the facility. Medications reviewed for all residents and it appears to be given as prescribed. Staff file reviewed to have required background and health screening. Infection control signs posted throughout the facility and LPA observed 30 days’ supply of PPE’s located in the garage. Last disaster drill conducted March 16th, 2022. Administrator certificate # 6049693735 expire 10/31/2023.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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