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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603189
Report Date: 10/23/2023
Date Signed: 10/23/2023 01:42:19 PM


Document Has Been Signed on 10/23/2023 01:42 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: 6DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Ralph Estanislao, adm assistantTIME COMPLETED:
01:00 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. Three (3) residents are on hospice. Administrator certificate is current and expiration date is 03/17/25. Annual fees are current.

During the visit, the CARE tool was used, facility tour was conducted, food supply was reviewed, staff/residents records were 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. Bathrooms, kitchen, common areas were inspected and in compliance. Two (2) days perishable and seven (7) days non-perishable were observed. Hot water temperature was in a range of 115.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Dual combo of smoke and carbon monoxide detectors are operable. Fire extinguishers are fully charged. Auditory devices are operable. 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 and this report was provided to Administrator assistant, Ralph.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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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