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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603139
Report Date: 04/11/2023
Date Signed: 04/11/2023 12:56:09 PM

Document Has Been Signed on 04/11/2023 12:56 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:MAXCELA HOMEFACILITY NUMBER:
198603139
ADMINISTRATOR:DE GUZMAN, FLORAFACILITY TYPE:
735
ADDRESS:6318 HARDWICK STTELEPHONE:
(562) 920-5635
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Ma Flora DeGuzmanTIME COMPLETED:
01:15 PM
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Licensing Program Analyst Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Caregivers Charlene Borla and Kimlan Suhalim who assisted with the visit, the Administrator Ma Flora DeGuzman assisted with the visit in the early am but had to leave for a scheduled training, returned later for the exit interview. The purpose for the visit was explained. 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 utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted in the living room.
Operational Requirements: There are currently 4 ambulatory residents residing at the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guest.
Physical Plant & Environment Safety: There are 5 bedrooms, 3 bathrooms, living room, dining room, kitchen, and an attached garage. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. Clean towels and extra linen were observed in a hallway closet. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathroom and kitchen were measured between 108.0-112.6 degrees F which are within the required range of 105-120 degrees. All bedrooms have all required furniture, lighting, and bedding. Passageways are free of obstruction and debris. The front and back yard are maintained well and there's a shaded area the back patio for resident to utilize.

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SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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: MAXCELA HOME
FACILITY NUMBER: 198603139
VISIT DATE: 04/11/2023
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Staffing: There appears to be sufficient staffing at the facility. The there are two administrators for this facility Ma Flora DeGuzman certificate expires 06/13/2024 and Rodrigo B DeGuzman certificate expires 6/13/2024. Staff employed are all over the age of 18 and have all certificates and training's up to date.
Personnel Records-Training: Staff files are maintained at the facility located in a locked cabinet in the living room. Staff have current CPR/first aid training and sufficient on-going training.
Resident Records-Incident Reports: Resident files are kept locked in a cabinet located in the living room and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted in the living room and are clearly visible.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Residents also attend day program, go on outings such as bowling and participate in extracurricular activities.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination. The sharp knives and utensils are locked in the kitchen cabinet. All the cleaning supplies and chemicals are locked in the cabinet in the laundry room and they are inaccessible for the residents.
Incidental Medical & Dental: The medications are centrally stored in a locked closet and are in their original containers. During the visit today, LPA reviewed all 4 residents' medication and 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.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.

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 to administrator Ma Flora DeGuzman
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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