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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602997
Report Date: 03/30/2022
Date Signed: 04/27/2022 11:55:04 AM


Document Has Been Signed on 04/27/2022 11:55 AM - 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:FAGAN HOME CAREFACILITY NUMBER:
198602997
ADMINISTRATOR:ANSELMO, YETZIRAFACILITY TYPE:
740
ADDRESS:19742 FAGAN WAYTELEPHONE:
(562) 215-3265
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:5CENSUS: 4DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Yetzira AnselmoTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Yetzira Anselmo and Assistant Administrator Wilber Pacheco and explained the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 562 215 3265.

The facility consist of four resident bedrooms, three bathrooms(1 in bedroom #1), 2 staff rooms, living room, dining room kitchen and covered patio located in the back yard, and an attached garage(storage).

During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of each room. A Pre screening area with PPE supplies was observed upon entry into the facility.

LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the kitchen. The water temperature was tested and measured 108.3 degrees F. The mitigation plan was approved on 04/06/2021.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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