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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603189
Report Date: 10/07/2022
Date Signed: 10/07/2022 05:31:36 PM


Document Has Been Signed on 10/07/2022 05:31 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:MAISON DE FLEURSFACILITY NUMBER:
198603189
ADMINISTRATOR:PAGANOS, GEORGEFACILITY TYPE:
740
ADDRESS:4918 N SUNFLOWER AVETELEPHONE:
(714) 606-1854
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 5DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Ralph Estanislao, Administrator AssistantTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Ralph Estanislao, Administrator Assistant. LPA explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and three (3) hospice waivers. Two (2) residents are on hospice. Administrator certificate is current and expiration date is 3/22/2024.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.

The facility is a single story house located in a residential neighborhood in Covina consisted of three (3) bedrooms, two (2) bathrooms, open living room, dining room next to the kitchen, laundry room, outdoor patio and a storage shed in the backyard.

Residents' bedrooms have dresser, chair and closet space available. Adequate linen and personal hygiene supply are observed. Adequate linen and personal hygiene supplies. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Stove tops are in working condition. Hot water temperature was in a range of 114.3 degrees Fahrenheit which was within Title 22 Regulation guidelines. Facility maintains a comfortable temperature of 72.4 degrees Fahrenheit for residents.
(-continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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: MAISON DE FLEURS
FACILITY NUMBER: 198603189
VISIT DATE: 10/07/2022
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Dual combo of smoke and carbon monoxide detectors are operable. Fire extinguishers are fully charged. Auditory devices are operable. The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored. Resident records are stored in a locked storage room and inaccessible to residents.

No deficiency is cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Administrator assistant, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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