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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603181
Report Date: 12/06/2022
Date Signed: 12/06/2022 04:18:37 PM


Document Has Been Signed on 12/06/2022 04:18 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:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Ivy RedjalTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with DSP Eulesa Natulac and explained the reason for the visit. Shortly after, the administrator Ivy G Redjal arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room, dining area, kitchen, laundry room, four clients bedrooms, two clients bathrooms, lounge area and a detached garage. All 4 clients bedrooms were toured. Each client room has one bed, one chair, one night stand, required bed linen, and furniture and sufficient lighting and closet space. All 2 bathrooms were toured and they are clean, sanitary and in a good working condition. The hot water temperature was tested between two bathrooms were tested between 107 and 110.3 which is within the Tittle 22 regulation. The refrigerator in the kitchen and the supply room has 2 days perishable and 7 days non-perishable food supply in the facility. The sharp knives and utensils are stored and locked in the kitchen drawers. All the kitchen appliances are working properly. The common area such as living room and dining area are clean and have the required furniture. The back yard has a shaded area with tables and chairs for clients to utilized. The smoke detectors and carbon carbon monoxide detectors are interconnected and they are working well.

LPA reviewed 4 client files to confirm emergency contact is updated on their file. LPA also reviewed two staff files to confirm health screenings and fingerprint clearances. They all have updated health screening in the personnel file and they are also fingerprint cleared. LPA also inspected 2 clients medication and they are all updated and accurate.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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: CROSSDALE RESIDENTIAL HOME, INC
FACILITY NUMBER: 198603181
VISIT DATE: 12/06/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the disinfecting products are available in common area and facility is disinfected two times every shift, bathrooms have sufficient soap, paper towels, and signs. PPE supplies are stored for 30 days.

No deficiencies were observed during the visit

Exit Interview conducted. A copy of the report was provided to the administrator Ivy G. Redjal

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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