198603087-8-10-2023-11-AS-FSHY-CUKLU7-20230810090328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603087
Report Date: 06/28/2023
Date Signed: 08/10/2023 09:03:32 AM

Document Has Been Signed on 08/10/2023 09:03 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
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:	06/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Ruth Gonzales		TIME COMPLETED:	12:00 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) Felisa Shirley conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. LPA met with Administrator in training, Ruth Gonzales, 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.

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.

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.

LPA walked through the kitchen and 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. The water temperature measured 115.4 degrees Fahrenheit.

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. LPA walked through the laundry room, all cleaning products were locked in a cabinet and inaccessible to residents.

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. 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.

con'd on 809 - C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

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: 06/28/2023

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

All exits are marked, and evacuation plans posted. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed in the garage. Sufficient paper, cleaning, and disinfecting supplies were observed. The garage is used as storage. LPA observed an ample supply of resident care items (diaper, mats). There was additional food and supplies stored.

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.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report provided to administrator.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2