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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602906
Report Date: 05/17/2023
Date Signed: 05/22/2023 07:52:39 AM

Document Has Been Signed on 05/22/2023 07:52 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CN HOME #9FACILITY NUMBER:
198602906
ADMINISTRATOR:JONALY V CAVITEFACILITY TYPE:
735
ADDRESS:2911 PACIFIC AVENUETELEPHONE:
(310) 612-0978
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 4CENSUS: 4DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Director Jonaly Cavite TIME COMPLETED:
03:15 PM
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On 05/17/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Jonaly Cavite and the purpose of today’s visit was explained. The facility is licensed to serve four (4) non-ambulatory adults ages 18 through 59, residents are South Central Regional Center residents.

The facility is a single-story home located in a residential neighborhood and consists of (4) resident bedrooms, (3) resident bathrooms, (1) staff bathroom, living room, dining room, kitchen, staff working area, attached garage with washer and dryer/ storage area, backyard with table and chairs.

LPA conducted a records review of (4) staff records (4) resident records and (4) Medication Administration Records and did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, first aid manual up to date. The facility disaster plan was current and in compliance with Title 22 at the time of visit. The last fire drill was conducted on 04/019/2023. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, (1) fire extinguisher is fully charged and mounted in the kitchen. Landline observed in kitchen and staff office area.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed, walls and floors were clean and in good repair, bed linens, comforters and bath towels were fully stocked. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CN HOME #9
FACILITY NUMBER: 198602906
VISIT DATE: 05/17/2023
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no discrepancies were observed.

Exit interview conducted with Administrator Jonaly Cavite and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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