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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602997
Report Date: 03/21/2023
Date Signed: 03/21/2023 03:49:20 PM


Document Has Been Signed on 03/21/2023 03:49 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: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:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator- Yetzira AnselmoTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon made and unannounced visit to conduct the Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. Upon arrival LPA met with Administrator Yetzira Anselmo.

LPA Calderon along side Yetzira Anselmo used Care Tools and conducted a tour of the facility. Tour consisted of living room, kitchen, dining room, 3 bathrooms, 5 client bedrooms (4 bedrooms occupied), backyard and attached garage.

Facility is licensed for Elderly clients age range 60 and over, 5 non-ambulatory of which 1 can be bedridden and 3 hospice wavier. Clients are associated with Harbor Regional Center. At this time there are no clients on Hospice, No bedridden and No Home Health.

LPA Calderon interviewed (3) clients, (1) client attempted interview and (3) staff interviews.

The following was conducted and inspected:
  • Outdoor and indoor passageways are free of obstruction.
  • Bathrooms were operable
  • Hot water measured between Title 22 regulations.
  • Smoke detectors and carbon monoxide are interconnected and were tested.
  • The last fire drill was conducted on 2/23/2023.
  • Liability Insurance: Effective Nov 9,2022 and Expires 11/09/2023
  • Required postings observed.
  • Fire extinguisher located in kitchen, garage, hallway and fully charged and serviced.
  • Sufficient supply of extra linen and towels stored inside the hallway cabinets.
  • Personal hygiene supplies located in garage, inaccessible to clients.
  • Facility temperature for clients was maintained at comfortable temperature.
  • Washer/Dryer appliances observed in garage.
  • Backyard has shaded area for clients, no large bodies of water was observed.
  • PPE was observed in back storage room and the garage.
(Continuation on 809-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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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: FAGAN HOME CARE
FACILITY NUMBER: 198602997
VISIT DATE: 03/21/2023
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KITCHEN:
  • Freezers/refrigerators appear sanitary and temperature maintained. There is an extra refrigerator and freezer in the garage.
  • Sufficient non-perishable and perishable food items for clients in care located in kitchen and in garage.
  • Emergency water and emergency food, emergency backpacks located in garage.
  • Sharps are locked inaccessible to clients.

BEDROOMS:
  • Rooms had required furnishing and in good condition.
  • Beds have the required linen/supplies.

MEDICATION:
  • Medications are stored, locked and inaccessible to clients, located in kitchen cabinet.
  • Medication and First Aid Kit/ Manual was reviewed.
  • LPA Calderon reviewed (4) client medications and Medication Log. Medications given as prescribed and documented properly.

RECORD REVIEW:
LPA Calderon reviewed Staff and Client files. As a part of the inspection reviewed (4) client records, (3) staff files.
  • Facility Administrator Certificate Expires:4/18/23
  • (4) Client file reviewed, no deficiencies.
  • (3) Staff files reviewed, all finger printed and trained, no deficiencies observed.

Care Tool was completed and based on Title 22 Regulations, no deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with Administrator Yetzira Anselmo and a copy of today's reports were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC809 (FAS) - (06/04)
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