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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602995
Report Date: 04/09/2024
Date Signed: 04/09/2024 12:20:38 PM


Document Has Been Signed on 04/09/2024 12:20 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:QFC LOVING CAREFACILITY NUMBER:
198602995
ADMINISTRATOR:ABESHYAN, HELENFACILITY TYPE:
740
ADDRESS:13652 ALDERTON LNTELEPHONE:
(562) 926-2802
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 6DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Helen Abeshyan TIME COMPLETED:
12:35 PM
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On 4/09/24 at 8:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to QFC Loving care. Upon arrival LPA was greeted by Direct Support Professional (DSP) Carmen Tiangco who contacted the Administrator. At 9:40 Administrator Helen Abeshyan arrived at the home and LPA explained the reason for the visit. This home is licensed to serve age range 60 and over. Approved for (6) non-ambulatory, of which 1 may be bedridden. Hospice waiver for (2) residents. There were (6) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 3/04/24. The Administrator Certificate expires on 5/15/2025 #6044818740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (6) resident files, medications, and medication administration records for (6) residents.

This home contains 3 bedrooms, 2 bathrooms, living room, playroom/ activities, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (3) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, shower with grab bar, shower chair, and bathmat. The temperature measured at 108.1*F-108.5*F. The smoke detectors were tested and observed to be working properly. The carbon monoxide detector was located in the hallway, tested, and functioning properly. There were (2) fire extinguishers located in kitchen and dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The knives secured in hallway cabinet. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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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: QFC LOVING CARE
FACILITY NUMBER: 198602995
VISIT DATE: 04/09/2024
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the residents. The dining room contained a non-working fireplace contained a covered screen so that it was inaccessible to the clients.

Exit interview conducted with Helen Abeshyan, Administrator, a copy of this report was provided, and Appeal rights given.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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