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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603167
Report Date: 07/11/2023
Date Signed: 07/11/2023 12:21:40 PM

Document Has Been Signed on 07/11/2023 12:21 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: 4DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:House Manager Julie MachadoTIME COMPLETED:
12:37 PM
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On 7/11/23 at 8:35 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Semora ARF Home. Upon arrival no one was at the facility. Direct Support Professional (DSP) Luz Portillo arrived at 8:45 am and contacted the House Manager, Julie Machado. This home is licensed to serve age range 18 through 59. Three (3) ambulatory and one (1) non-ambulatory. The home is vendored through Harbor Regional Center. There were (2) clients in care during the time of this visit, the other (2) clients were at the day program. The last emergency disaster/fire drill was conducted on 7/08/23. The Administrator Certificate expired on 12/20/2022 #6022703735. LPA verified the administrator’s certificate is pending online. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (2) staff files, (4) client files, medications, and medication administration records for (4) clients and P&I.

This home contains 4 bedrooms, 2 bathrooms, living room, office space, kitchen, dining room, backyard with a shed and an attached garage. LPA toured the physical plant with the House manager, and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 109.9*F-116.5*F. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in kitchen and garage fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked underneath kitchen sink with cleaning agents and toxins. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SEMORA ARF INC
FACILITY NUMBER: 198603167
VISIT DATE: 07/11/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. LPA observed a shed containing supply cabinets in the backyard. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients. The living room contained activity supplies available to the clients.

The office space contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, support services, community resources and client hygiene schedule.

Exit interview conducted with Julie Machado, House Manager, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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