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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603181
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:18:17 PM

Document Has Been Signed on 08/22/2023 03:18 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:CROSSDALE RESIDENTIAL HOME, INCFACILITY NUMBER:
198603181
ADMINISTRATOR:REDJAL, IVY GFACILITY TYPE:
735
ADDRESS:15209 CROSSDALE AVENUETELEPHONE:
(714) 883-8349
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Ivy Redjal, administratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with Ivy Redjal, Administrator and discussed the purpose of today's visit. Facility is licensed to serve four (4) clients, non-ambulatory, ages from 18 to 59. All four (4) clients receive case management services provided by Harbor Regional Center. Annual fees are current.

During the visit, the Care tool was used, a tour of the facility was conducted, food supply was reviewed,
staff/clients files were reviewed and medications were reviewed.

Facility is a single family house consisted of four (4) clients' bedrooms, two (2) bathrooms, living room, dining area, kitchen, laundry area, staff lounge room, detached garage and an outdoor activity area in the back yard. All outdoor and indoor passageways are free from obstruction.

Common areas were observed for the ability to safely serve the needs of the clients. All client rooms were furnished with appropriate furniture for clients’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Hot water temperature was 116.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Facility maintained a comfortable temperature for clients. Sufficient supply of perishable and non-perishable foods was observed. Back yard activity area was a shaded area with chairs and free of debris/ hazard. Smoke and carbon monoxide detectors were tested and operational. First aid kit was fully stocked with manual. The last Fire/ Emergency Drill was conducted on 8/12/23.



Fire extinguishers were fully charged. Medications were centrally stored, locked and the records were current. Hazardous items, knives and sharp items were locked and inaccessible to clients.

No deficiencies were cited per California Code of Regulations, Title 22.

Exit conference was conducted with administrator. This report, LIC809s, were provided to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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