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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603130
Report Date: 09/20/2022
Date Signed: 09/20/2022 10:38:07 AM

Document Has Been Signed on 09/20/2022 10:38 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
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:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Tes Sison, AdministratorTIME COMPLETED:
10:40 AM
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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 Tes Sison and explained the purpose of the visit. There are four (4) ambulatory level 4E 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/emergency drill was conducted on 9/1/2022. Administrator certificate expires 10/5/2023.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility is equipped with a fire pull alarm system. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • Room #3 is designated as a COVID-19 isolation room if needed and/or client private room if applicable.
  • A posted Emergency Disaster Plan was observed.
  • Three (3) centrally stored client medication records were reviewed. Medications are documented properly and given as prescribed.
  • Staff were observed wearing mask. Clients were observed wearing masks and/or face shields.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • All staff have fingerprint clearances. Staff and resident files were not reviewed during today's visit.


Per California Code of Regulations, Title 22, there were NO deficiencies observed during the visit.
Exit interview was conducted with Administrator Tes Sison. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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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