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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603207
Report Date: 12/23/2021
Date Signed: 12/24/2021 10:44:18 AM

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 IVFACILITY NUMBER:
198603207
ADMINISTRATOR:BISNAR, LOURDESFACILITY TYPE:
740
ADDRESS:11511 THOMAS PLACETELEPHONE:
(562) 202-3670
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 4DATE:
12/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lourdes Bisnar TIME COMPLETED:
05:00 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 562 202 3670 and/or 562 864 3608.

The facility consist of four resident bedrooms, two bathrooms, a living room, dining room, kitchen and patio located in the back yard and an attached garage used for storage and overflow of food.

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 facility mitigation plan was reviewed and approved on 05/22/2021.

LPA 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 between 105 and 120 degrees F.

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: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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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