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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603130
Report Date: 09/16/2021
Date Signed: 09/16/2021 02:58:26 PM

Document Has Been Signed on 09/16/2021 02:58 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MS FAMILY HOME LLCFACILITY NUMBER:
198603130
ADMINISTRATOR:SISON, TESFACILITY TYPE:
735
ADDRESS:13649 E RUSSELL STTELEPHONE:
(562) 945-5425
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 4CENSUS: 4DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Sison Tes, AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Sison Tes and explained the purpose of the visit. There are 4 level 4E ambulatory developmentally disabled clients in the home. The facility is a single story home licensed for 3 ambulatory and 1 non-ambulatory clients located in a residential neighborhood. It consists of 3 resident bedrooms, 1 staff room, 3 bathrooms, dining room, kitchen, living room, family room, outdoor patio, and attached garage. The last fire drill was conducted on 9/1/2021. Administrator certificate expires 10/5/2021.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected.
  • COVID-19 Infection Control Practices and signs were observed in the entrance, common areas, hallways, bathrooms and resident rooms.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart.
  • Facility has one (1) designated isolation room.
  • Three (3) centrally stored resident medication records were reviewed.
  • All staff were observed wearing mask.
  • Due to client's disability and behaviors none of the clients in care were observed wearing masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed. .
  • Staff and resident files were not reviewed during today's visit.


There were no deficiencies cited.

Exit interview was conducted with Administrator Tes Sison. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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