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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602883
Report Date: 04/22/2022
Date Signed: 04/22/2022 03:47:44 PM

Document Has Been Signed on 04/22/2022 03:47 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:SANDRA'S HOUSE LLC #3FACILITY NUMBER:
198602883
ADMINISTRATOR:BENSON, SANDRAFACILITY TYPE:
735
ADDRESS:1908 STEVELY AVETELEPHONE:
(562) 843-8522
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 4CENSUS: 4DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:April GoremanTIME COMPLETED:
03:45 PM
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 On 04/22/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced visit to the facility for purpose of an annual inspection, with an emphasis on infection control using Care Tools. LPA met with Administrator April Gorman and the purpose of the visit was explained. Upon Arrival LPA was screened for Covid-19, and temperature was taken and logged.

The facility is vendorized through Harbor Regional Center as a level 4I home which licensed for 4 ambulatory of which 1 may be non-ambulatory.

The facility is a single story home with four (4) bedrooms, two (2) bathrooms , kitchen/laundry area, living room, dining area, small back yard with table and adequate chairs with covered and attached garage and used as storage. There's no bodies of water on the premises. All outdoor and indoor passageways are free of obstruction.
All bedroom has one bed, one chair, one night stand, drawer, closet and adequate lighting. Bedroom#4 is for the non-ambulatory client with an exit door. All bathrooms have a working toilet, wash basin, bath-tub/shower.
Bathroom #2 is accommodated for the non-ambulatory clients in a wheelchair. Hot water was measured at 105.2 which is within title 22 regulations.

The smoke detectors and carbon monoxide detectors are located in each bedroom and common area. They are all interconnected and working properly. Last fire drill was conducted 04/01/22, LPA observed one active fire extinguisher located in Dinning room.

All the cleaning solutions are locked and stored in the kitchen cabinet and they are inaccessible to clients.

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SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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: SANDRA'S HOUSE LLC #3
FACILITY NUMBER: 198602883
VISIT DATE: 04/22/2022
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4 client files were reviewed, and had required documents. 2 staff files were reviewed and had the required documents.

The medications are centrally stored and locked in a locked file cabinet in the dining area and is only available for staff to use but inaccessible to clients. 1 Medication Administration Record was reviewed. Medications were documented properly and seem to be given as prescribed.

Covid-19 Procedures were discussed with Administrator. Facility sanitizes every shift. Facility has adequate amount of Surgical Masks, N95's,Face shields, Gowns, gloves, sanitizers, soap, and paper towels. Facility log's covid screenings for visitor, staff and clients. All Covid-19 vaccination status are kept on file.

Technical Advisory given for the following areas:

N95 Fit testing per Pin 21-09ASC; 21-10ASC
Designation of Responsibility LIC 308

No citations were issued during this visit.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
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