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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602916
Report Date: 02/15/2023
Date Signed: 02/15/2023 03:35:04 PM

Document Has Been Signed on 02/15/2023 03:35 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:
02/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Samira Menendez, AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Lizeth Curiel and explained the purpose of the visit. Administrator Samira Menendez arrived shortly after. There are currently four (4) ambulatory level 4i disabled clients ages of 18 through 59 serviced by South Central Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood. It consists of 3 client bedrooms, 2 bathrooms, kitchen, dining area, living room, outdoor patio, attached garage with laundry area. The last fire/emergency drill was conducted on 10/3/2022. Administrator recertification is pending processing. Documents were submitted in Nov. 2022.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, and bathrooms. Visitors are screened upon entry.
  • Room #2 is designated as a COVID-19 isolation room if needed.
  • A posted Emergency Disaster Plan was observed.
  • Centrally stored medications/30-day supply of medications were reviewed.
  • Staff were observed wearing mask. Clients do not wear masks due to disability exemption.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C).
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • The facility submitted a COVID-19 Mitigation Plan and Infection Control Plan (ICP).
  • Submit the ICP as soon as possible. The plan should be reviewed and updated as necessary.
No deficiencies were cited.
Exit interview was conducted with Administrator Samira Menendez. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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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