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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602916
Report Date: 03/14/2022
Date Signed: 03/14/2022 02:42:01 PM

Document Has Been Signed on 03/14/2022 02:42 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA KLINEDALEFACILITY NUMBER:
198602916
ADMINISTRATOR:MENENDEZ, SAMIRAFACILITY TYPE:
735
ADDRESS:9243 KLINEDALE AVENUETELEPHONE:
(562) 440-7531
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 4CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Samira Menendez - AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Samira Menendez and explained the reason for the visit. The facility is licensed to serve 4 ambulatory clients only in the age range of 18 through 59. The facility is in a residential area. A tour of the single-story facility included: 3 client bedrooms, 2 bathrooms, kitchen, dining area, living room, laundry area, attached garage, front yard, and backyard.

LPA Mora conducted the tour with Samira Menendez and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in a closet near the kitchen. Chemical and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept locked in a file cabinet located in the living room and it is fully stocked with all required items including a current manual. There are clean towels and extra linen in the laundry area. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet located in the living room. All bedrooms have all required furniture, lighting, and bedding. The 2 bathrooms were observed with shower mats. The water temperature was tested and measured at 105.3 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. A carbon monoxide was observed in the kitchen and was operable during the visit. The front yard and backyard are clean. There is a shaded seating area in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for all four clients. Medications are documented properly and given as prescribed. Client and staff files were not reviewed in today’s visit. LPA observed administrator certificate for Samira Menendez – 6014412735 with an expiration date of 07/25/2022.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CASA KLINEDALE
FACILITY NUMBER: 198602916
VISIT DATE: 03/14/2022
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Facility has 30 days supplies of Personal Protective Equipment in a closet near the kitchen and also in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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