<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603031
Report Date: 10/18/2022
Date Signed: 10/18/2022 03:54:47 PM

Document Has Been Signed on 10/18/2022 03:54 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANZAC RESIDENTIAL CAREFACILITY NUMBER:
198603031
ADMINISTRATOR:ROBINSON, ANDREAFACILITY TYPE:
735
ADDRESS:12323 S ANZAC AVETELEPHONE:
(310) 901-5428
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 6CENSUS: 1DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Andrea RobinsonTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA conducted Covid-19 risk passement before entering the building. LPA was met by Andrea Robinson, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve clients age range 18 through 59. approved to serve 6 ambulatory clients.

There is currently 1 client at the facility that at came from Brilliant Corners. The facility is a single-story structure located in a residential neighborhood. It consists of the following: a living room, kitchen, dining room, 4 bedrooms, 2 bathrooms (1 for staff), laundry area, garage, front and back yard.

LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, storage for client personal belongings was observed. Walls and floors were in good repair. LPA did observe all rooms had adequate lighting. linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 106.7F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there are enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. LPA observed client record and medication was locked and stored.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings throughout the facility. LPA did not observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LIC 809-C Is on the next page

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANZAC RESIDENTIAL CARE
FACILITY NUMBER: 198603031
VISIT DATE: 10/18/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

Exit interview held and a copy of the report and appeal rights were provided to Andrea Robinson.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4