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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602890
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:26:55 PM

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:J AND C HOUSE OF LOVEFACILITY NUMBER:
198602890
ADMINISTRATOR:WISE, CHANTEFACILITY TYPE:
740
ADDRESS:12121 164TH STREETTELEPHONE:
(562) 229-9957
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 4DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Chante Smith (Administrator)TIME COMPLETED:
01:00 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 Chante Smith (Administrator) and explained the purpose of the visit. The facility is licensed to serve age 60 and over. Approved for 6 non-ambulatory of which three may be hospice residents.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, attached garage, dining area, kitchen, 4 resident bedrooms, 1 staff room, 4 bathrooms and a laundry room.

During today's visit, LPA observed the following: Facility is operating within capacity. There are no pools or large bodies of water on the premises. Facility maintains a comfortable temperature for residents. All outdoor and indoor passageways are free of obstruction. Hot water temperature measured at 109.5 degrees F in bathroom #1. Grab bars for each toilet, bathtub and shower used by residents were observed. Bathtub or shower have non-skid mats or strips. There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods. All readily perishable foods or beverages capable of growth of micro-organisms are stored in covered containers at appropriate temperature. The facility has sufficient and competent staff to provide the services needed to meet resident needs. Staff assisting residents with ADLs have received required training. Criminal Record Clearance for all required persons is associated to the license. LPA was allowed to enter the facility to conduct inspections. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Medications is given per the physician’s directions. There is signed and dated written order from a physician for every prescription and nonprescription PRN medication. Centrally stored medicines is kept in a safe and locked place.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Chante Smith.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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