198603087-1-6-2023-11-AS-WGIS-CMU2VZ-20230106164446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603087
Report Date: 12/30/2022
Date Signed: 01/06/2023 04:44:51 PM

Document Has Been Signed on 01/06/2023 04:44 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:	CN HOME #8		FACILITY NUMBER:	198603087
ADMINISTRATOR:	CAVITE, JONALY		FACILITY TYPE:	735
ADDRESS:	4743 W 166TH ST		TELEPHONE:	(310) 612-0978
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY: 4		CENSUS:	DATE:	12/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Jonaly Cavite		TIME COMPLETED:	01:30 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) Wendy Gibbs conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. LPA met with Administrator, Jonaly Cavite and the purpose of this visit was explained. The facility is licensed for 4 non-ambulatory clients; and there are currently four (4) residents in placement.

Structure The facility is a single story home in a residential neighborhood with a driveway. The facility consists of a living room, family room, dining room, kitchen, six (6) bedrooms, two (2) full bathrooms, laundry room, activity room and an attached garage.

Physical Plant The LPA walked the outside of the facility. In the back yard there is a table, chairs and umbrella for residents and visitors use. All walkways were clear of debris, obstructions and hazards. LPA did not observe any bodies of water.

Bedrooms LPA walked through all six (6) rooms. Bedrooms 1-4 are designated for the resident’s individual use. All bedrooms contained a bed, dresser, nightstand, chair, ample lighting and closet space. Room 5 is the designated activity room and Room 6 is designated as an office.

Bathrooms All bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly. The walk-in shower was free of mildew and mold and had shower chairs available. The water temperature measured 108.9-110.1-degrees Fahrenheit.

Laundry/Linens LPA walked through the laundry room, all cleaning products were locked in a cabinet and inaccessible to residents. LPA observed an ample supply of linens stored in a cabinet.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2022

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 2

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: CN HOME #8	FACILITY NUMBER: 198603087
	VISIT DATE: 12/30/2022

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

Kitchen All appliances were in good working order. Knives were locked and stored in a drawer in the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. All cutleries were in good condition. The water temperature measured 116.8-degrees Fahrenheit.
Garage The garage is used as storage. LPA observed an ample supply of resident care items (diaper, mats). There was additional food and supplies stored.
Common Areas LPA walked through all common areas. In the living room, family room, dining room and activity room there is ample seating and space for all residents. LPA observed games and activities for residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting.

Safety All rooms, hallway, family room and living room have working smoke detectors. Carbon monoxide detector was functional. There is a fully charged fire extinguisher in the dining room. All exits are marked, and evacuation plans posted. Last emergency drill was on 12/09/2022. There is a working landline. All necessary numbers and signs are posted. LPA observed a First Aid kit with all the required item and a manual.

Infection Control During the tour, LPA observed the facility’s infection control practices. Upon entry LPA was Covid screened, temperature was taken, and was asked a series of questions. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 60-day supply of PPE was observed in the garage. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed all staff wear a face covering. LPA observed required postings throughout the facility.

Medications Centrally stored medications were observed and inaccessible to residents. LPA reviewed the mars and matched them to all residents medications.

Files LPA reviewed all resident files, which contained all the required documentation. LPA reviewed staff files which contained all the required documentation and certification.

LPA reviewed the Surety Bond.
No deficiencies were cited during this visit.
An exit interview was conducted, and a copy of this report provided to administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2