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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603111
Report Date: 09/15/2023
Date Signed: 09/15/2023 02:01:18 PM

Document Has Been Signed on 09/15/2023 02:01 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A & A CARE HOMEFACILITY NUMBER:
198603111
ADMINISTRATOR:CABALLES, CRISTINAFACILITY TYPE:
735
ADDRESS:21207 WILDER AVETELEPHONE:
(562) 233-3125
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Cristina Caballes - AdministratorTIME COMPLETED:
02:16 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Cristina Caballes (Administrator) and explained the reason for the visit. The facility is licensed to serve 1 ambulatory and 3 non-ambulatory clients ages 18-59. The facility is operating within the scope of its license.

A tour of the single-story facility included: 4 client bedrooms, 2 bathrooms, kitchen, dining room, living room, activity room, backyard, attached garage. LPA Mora conducted the tour with Cristina Caballes and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet and in each bedroom. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a kitchen cabinet. Client and staff files are kept locked in the activity room. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats and have the required grab bars for non-ambulatory clients. The water temperature was tested in both bathrooms and measured at 116.4 degrees F and 117.3 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and were operable during the visit. A carbon monoxide was observed in the kitchen and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for all 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 clients and 5 staff. No issues were observed with the files. LPA observed administrator certificate for Cristina Caballes - 6045504735 with an expiration date of 08/20/2023. Administrator provided LPA proof of renewal prior to the expiration date and she is currently waiting for the new certificate. LPA interviewed 2 staff and 2 clients. (Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A & A CARE HOME
FACILITY NUMBER: 198603111
VISIT DATE: 09/15/2023
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Per California Code of Regulations, Title 22, and California Health and Safety Code, there are no deficiencies observed during the visit. Exit interview held and a copy of the report were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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