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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602914
Report Date: 02/28/2024
Date Signed: 03/11/2024 05:10:50 PM


Document Has Been Signed on 03/11/2024 05:10 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:JOTAG HOMECAREFACILITY NUMBER:
198602914
ADMINISTRATOR:RULL, BENITEZ EVELYNFACILITY TYPE:
740
ADDRESS:14723 VAN BUREN AVENUETELEPHONE:
(310) 612-1897
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:6CENSUS: 6DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chillie House, CaregiverTIME COMPLETED:
01:00 PM
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On 02/28/24, Licensing Program Analysts (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with the Administrator/Licensee Evelyn Benetiz Rull. LPA Shirley explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory adults (ages 60 and over). Currently, the facility has six (6) residents.

The Facility is a single-story family home with five (5) bedrooms, two (2) full bathrooms, dining room, kitchen, living room, and a two (2) car detached garage.

LPA Shirley and Evelyn walked through the kitchen and all appliances were in good working order. Knives were locked and stored in the drawer in the kitchen, medications were locked in a closet off the living room and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 110.2 degrees Fahrenheit.

Each bedroom has ample lighting, chair, spacing, beds, bedding, and storage space. Two (2) full bathrooms have a working toilet, wash basin, bathtub/shower.



LPA observed the facility is clean, sanitary, and in good repair. Indoor and outdoor passageways, and other areas of potential hazard are free of obstructions. Facility temperature is between 68° degrees and 85° degrees. Carbon monoxide/Smoke detectors operate properly.

There are ample amounts of first-aid supplies and first-aid manual. There is working washer and dryer located in the garage. The backyard is clean and clear of obstructions and hazards, two shaded areas for sitting and there are no bodies of water present.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of this report was provided to Administrator/Licensee, Evelyn Rull.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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