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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603193
Report Date: 06/01/2023
Date Signed: 06/01/2023 03:38:49 PM


Document Has Been Signed on 06/01/2023 03:38 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:CERRITOS ASSISTED LIVINGFACILITY NUMBER:
198603193
ADMINISTRATOR:SANTA ANA, OSVALDOFACILITY TYPE:
740
ADDRESS:18511 KAMSTRA AVENUETELEPHONE:
(562) 637-3392
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 4DATE:
06/01/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Administrator Edith ParrenoTIME COMPLETED:
04:00 PM
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On 6/1/23 at 1:06 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Cerritos Home Care. Upon arrival LPA was greeted by Direct Care Staff (DSP) Judith Delos Reyes who contacted the Administrator, Edward Parreno, at 1:10 p.m. to assist with today's visit. Administrator Edith Parreno arrived at 2:50 pm and assisted with the visit. This home is licensed to serve (4) non-Ambulatory developmentally disabled adult’s clients with restricted health conditions. The is a level 4I home and the vendor is Harbor Regional Center. There were (3) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 5/5/2023. The Administrator Certificate expires on 6/10/2023 #6043620735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (4) client files, medications, medication administration records for (4) clients and P&I. LPA (2) interviewed staff and due to all clients limited communication LPA could not proceed with client interviews.

This home contains 4 bedrooms, 2 bathrooms, living room, office, kitchen, dining room and an attached garage. LPA toured the physical plant 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 112.6*F-116.9*F. The smoke detectors were battery operated and individually tested and observed to be working properly.

(Report continued on LIC809C.)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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: CERRITOS ASSISTED LIVING
FACILITY NUMBER: 198603193
VISIT DATE: 06/01/2023
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The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (1) fire extinguisher located in kitchen and dining room 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.

The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and storage.


Exit interview conducted with Edith Parreno, Administrator, a copy of this report was provided, and Appeal rights given.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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