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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603206
Report Date: 11/09/2021
Date Signed: 11/23/2021 10:37:23 PM

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:LOVING ARMS RESIDENTIAL CARE FOR SENIORS IIFACILITY NUMBER:
198603206
ADMINISTRATOR:LI, CRYSTALFACILITY TYPE:
740
ADDRESS:11503 THOMAS PLTELEPHONE:
(408) 893-2746
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 3DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lourdes BisnarTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Lourdes Bisnar and explained the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 562 484-0609.

The facility consist of four resident bedrooms, two bathrooms, living room, dining room, kitchen, covered patio located in the back yard, and an attached garage(storage).

During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of each room. A Pre screening area with PPE supplies was observed upon entry into the facility. The Mitigation plan was reviewed and approved on 05/22/2021.

LPA Wesley conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the kitchen. The water temperature was tested and measured 119.5 degrees F.

Administrators certificate for Crystal Li #6051057740, expires on 02/05/2023.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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