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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603139
Report Date: 04/26/2022
Date Signed: 04/26/2022 10:49:48 AM

Document Has Been Signed on 04/26/2022 10:49 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:MAXCELA HOMEFACILITY NUMBER:
198603139
ADMINISTRATOR:DE GUZMAN, FLORAFACILITY TYPE:
735
ADDRESS:6318 HARDWICK STTELEPHONE:
(562) 920-5635
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 4DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Charlen Borla - CaregiverTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with caregivers Charlene Borla and Kim Lan Suhalim and explained the reason for the visit. The facility is licensed to serve 3 ambulatory and 1 non-ambulatory clients ages 18 to 59 years old, and a hospice waiver for one client. The facility is in a residential area. A tour of the single-story facility included the living room, dining area, kitchen, laundry room, 4 client bedrooms, 1 staff bedroom, 2 client bathrooms, 1 staff bathroom, attached garage, front yard, and backyard.

LPA Mora conducted the tour with Charlene Borla 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 were observed locked under the kitchen sink. Chemical and cleaning solutions are kept locked in the laundry room. The First Aid kit is kept locked in the medication closet in the hallway and it is fully stocked with all required items including a current manual. Clean towels and extra linen were observed in a hallway closet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in the medication closet in the hallway. Client and staff files are kept locked in a cabinet located in the living room. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in all 3 bathrooms and measured at 113 degrees F, 107 degrees F and 107.5 degrees F, which is within the required 105-120 degrees F. Two fire extinguishers were observed in the kitchen and living room and are fully charged. Smoke detectors combined with carbon monoxide were observed throughout the facility and in each room and were 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.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MAXCELA HOME
FACILITY NUMBER: 198603139
VISIT DATE: 04/26/2022
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LPA reviewed medication for all four clients. Medications are documented properly and given as prescribed. LPA reviewed files for all four clients and two staff. There were no issues found with the files. LPA observed administrator certificate for Ma Flora S DeGuzman - 6017200735 with an expiration date of 06/13/2022.

Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.


Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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