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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602909
Report Date: 02/22/2022
Date Signed: 02/22/2022 03:47:52 PM

Document Has Been Signed on 02/22/2022 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:CN HOME # 4FACILITY NUMBER:
198602909
ADMINISTRATOR:MARTHA A FLORESFACILITY TYPE:
735
ADDRESS:6470 PARAMOUNT BLVDTELEPHONE:
(562) 422-2389
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 4CENSUS: 4DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Martha "Shelly" FloresTIME COMPLETED:
03:45 PM
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On 02/22/22 Licensing Program Analyst (LPA) Jade Jordan conducted an annual inspection, with an emphasis on infection control. LPA was met by Facility Administrator Martha "Shelly" Flores, and the purpose of the visit was explained.

The facility is a single story house located on a primary street. The interior consist of a living room, dining area, kitchen, 4 clients bedrooms, 2 bathrooms, staff office, and closeted laundry area. The exterior consists of a gated front yard landscape, with a gated drive way leading to a shaded patio area, and a locked detached garage, and 2 sheds, also used for storage. Passageways, walkways, driveway, steps and patios are free of obstructions. No bodies of water are present on the premises. The client bedrooms have the required furnishings. 1 bed is located in each room. The beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Each room has 1 chair, lamp/overhead lighting, 1 dresser, and closet space. There is no bedroom designated for awake-staff. There are 2 bathrooms, each have a working toilet, wash basin, bathtub, required grab bars and skid mats. Bathrooms were clean and free of mold/mildew. Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review in the living room. There is 1 Fire Extinguisher located in the kitchen, last serviced in 2021. Telephone system is a land line located in the dining area. Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer in the kitchen. Food supply adequately stored in kitchen cabinets. Dishwasher in kitchen properly installed and functioning. Smoke Detectors and Carbon monoxide detector are operational, fire drills are conducted on a monthly basis. Stove burners, microwave, washer, dryer are operational. There is one refrigerator in the kitchen. Toxins are locked and stored. Water Temperature tested at 110 degrees F in the bathroom #1.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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: CN HOME # 4
FACILITY NUMBER: 198602909
VISIT DATE: 02/22/2022
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LPA Reviewed Resident Records, staff files and medication records.


Infection Control:
LPA Observed that each client bedroom had a minimum of 30 day supply of ppe in their own room. Supplies observed in individual carts, included : face shields, N95 mask, gowns and gloves. Readily available was hand sanitizers, soap, paper towels, and a thermometer to check temperatures. The facility had required posting of Hand Hygiene, Social Distancing, Covid 19 , updated emergency contacts, and keeps a log of daily sanitation, and visitors screenings for Covid-19. LPA was screen at entry of home, and temperature was taken before entering. The facility is currently following their mitigation plan, and has no active Covid within the home. Facility has conducted their N95 fit testing and in compliance with Cal Osha regulations.

An exit interview was conducted, and a copy of this report was provided. No deficiencies were issued during this visit.


SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC809 (FAS) - (06/04)
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