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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602970
Report Date: 05/11/2021
Date Signed: 05/12/2021 08:22:23 AM

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:SOMERSET HOMECAREFACILITY NUMBER:
198602970
ADMINISTRATOR:IGLESIAS, JOVANFACILITY TYPE:
740
ADDRESS:1309 E SOMERSET PLTELEPHONE:
(562) 612-0436
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 4DATE:
05/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:licensee jovan iglesiasTIME COMPLETED:
03:15 PM
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On 05/11/2021 on around 12:30 pm Licensing Program Manager (LPM) Janae Hammond and Licensing Program Analyst LPA Jose Calderon, conducted a required annual inspection with primary focus on infection control measure. LPA was greeted by Licensee Jovan Iglesias in person. The facility is a 4 bedroom 3 bathroom with 4 clients living at the facility. As a part of the inspection, LPM and LPA reviewed client service records, client P & I records, personnel records, medications. LPA inspected the inside/outside facility grounds.

LPA conducted a review of (4) client service records and (1) personnel records. LPA conducted a review of P&I and Medication Administration Record (MAR) and medications. All medications and records are maintained in compliance with label instructions. All records are maintained in order.

LPA along with Mr. Iglesias toured the entire facility inside and outside grounds. This home consists of (4) client bedrooms (4) client bathrooms. A living room, kitchen, dining area, activity room, laundry area and patio. During the inspection LPA observed the following client rooms: mattresses and box springs in working condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. LPA observed fully stocked bedding and towel in closets. All bathroom fixtures are in working condition. LPA observed sufficient bedding, linens, and toiletries are accessible to clients. Water temperature properly measured at 109.0 degrees F.

There were (4) clients present during the inspection. There were adequate perishable and non-perishable food supply were kept at the home and fully stocked in kitchen cabinets. LPA tested facility Carbon Monoxide and Smoke Detectors and are working properly.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
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: SOMERSET HOMECARE
FACILITY NUMBER: 198602970
VISIT DATE: 05/11/2021
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The facility has (1) Fire Extinguisher fully charged. All disinfectants, cleaning solutions and toxins were in locked cabinets. Medications are stored in locked cabinet in kitchen area and inaccessible to clients. Facility first aid kit was checked and in compliance. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. The facility has a functional operating landline telephone in kitchen area. All mandated posters were displayed on walls. Administrator Certification Program expires 07/12/2022 for Jovan Iglesias

According to the California Code of Regulations (Title 22, Division 6, Chapter 1), LPA did observed no deficiencies, no citations are issued.



An exit interview was conducted, and a Facility Evaluation Report were provided to Jovan Iglesias.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
LIC809 (FAS) - (06/04)
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