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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603167
Report Date: 03/17/2023
Date Signed: 03/17/2023 03:02:31 PM

Document Has Been Signed on 03/17/2023 03:02 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:SEMORA ARF INCFACILITY NUMBER:
198603167
ADMINISTRATOR:MACHADO, MARY LFACILITY TYPE:
735
ADDRESS:10609 SEMORA STTELEPHONE:
(714) 676-7005
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 1DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:House Lead-Julie MachadoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Ashley Calderon made and unannounced visit to conduct the Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. Upon arrival LPA met with House Lead Julie Machado

LPA Calderon along side Julie Machado used Care Tools and conducted a tour of the facility. Tour consisted of living room, kitchen, dining room, 2 bathrooms, 4 client bedrooms, backyard and attached garage.

LPA Calderon interviewed (1) clients, (2) attempt client interviews and (2) staff interviews.

The following was conducted and inspected:
  • Outdoor and indoor passageways are free of obstruction.
  • Bathrooms were operable and hot water measured between Title 22 regulations.
  • Smoke detectors and carbon monoxide are interconnected and were tested.
  • The last fire drill was conducted on 3/08/2023.
  • Required postings observed.
  • Fire extinguisher located in kitchen, fully charged.
  • Sufficient supply of extra linen and towels stored inside the hallway cabinets.
  • Personal hygiene supplies located in bathroom for clients and extra in garage.
  • Facility temperature for clients was maintained at comfortable temperature.
  • Washer/Dryer appliances observed in garage.
  • Backyard has shaded area for clients, no large bodies of water was observed.
  • PPE was observed around the house and the garage.
(Continuation on 809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SEMORA ARF INC
FACILITY NUMBER: 198603167
VISIT DATE: 03/17/2023
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KITCHEN:
  • Freezers/refrigerators appear sanitary and temperature maintained. There is an extra refrigerator and freezer in the garage.
  • Sufficient non-perishable and perishable food items for clients in care located in kitchen and in garage.
  • Emergency water located in garage and backyard. Canned goods stored in pantry cabinets and garage.
  • Sharps are locked inaccessible to clients.

BEDROOMS:
  • Rooms had required furnishing and in good condition.
  • Beds have the required linen/supplies.

MEDICATION:
  • Medications are stored, locked and inaccessible to clients, located in kitchen cabinet.
  • Medication and First Aid Kit/ Manual was reviewed.
  • LPA Calderon reviewed (4) client medications and Medication Log. Medications given as prescribed and documented properly.

RECORD REVIEW:
LPA Calderon reviewed Staff and Client files. As a part of the inspection reviewed (4) client records, (4) staff files.
  • Facility Administrator Certificate for Mary Machado is up to date.
  • (4) Client file reviewed, no deficiencies.
  • (4) Staff files reviewed, all finger printed and trained, no deficiencies observed.

Care Tool was completed and based on Title 22 Regulations, no deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with House Lead Julie Machado and a copy of today's reports were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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