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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602997
Report Date: 02/20/2024
Date Signed: 02/20/2024 11:54:17 AM


Document Has Been Signed on 02/20/2024 11:54 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:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Yetzira Anselmo TIME COMPLETED:
12:08 PM
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On 2/20/24 at 8:45 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Fagan Home Care. Upon arrival LPA was greeted by Direct Support Professional (DSP) Elizabeth Berunen who contacted the Administrator, Yetzira Anselmo. At 9:00 the Administrator arrived and assisted with today's visit. This home is licensed to serve age range 60 and over, with 5 non-Ambulatory, of which 1 may be bedridden. Hospice wavier approved for 3. The facility is a level 4I home and the vendor is Harbor Regional Center. There were (4) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 01/10/24. The Administrator Certificate expires on 04/18/2025 #6044039740. 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, (4) resident files, medications, and medication administration records for (4) residents and P&I.

This home contains 5 bedrooms, 3 bathrooms, living room, Enclosed patio, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The three bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 106.5*F-109.7*F. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (3) fire extinguishers located in kitchen, garage and enclosed patio 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 were secured and locked in kitchen drawer. The cleaning agents and toxins was locked underneath the kitchen sink. 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: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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: FAGAN HOME CARE
FACILITY NUMBER: 198602997
VISIT DATE: 02/20/2024
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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. 2 shed was in the backyard and are used for storage supplies. 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 living room contained a working fireplace currently not in use. The fireplace contained a covered screen so that it was inaccessible to the residents.

The living room/office contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

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

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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