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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603237
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:45:35 PM

Document Has Been Signed on 12/08/2023 03:45 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:NURTURE HOME CAREFACILITY NUMBER:
198603237
ADMINISTRATOR:TORRES, PRINCESS WILYNFACILITY TYPE:
735
ADDRESS:13651 BARLIN AVENUETELEPHONE:
(424) 362-6566
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 6CENSUS: 3DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:House Lead Manager - Derry SamdijamTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced annual visit at the facility with focus on the CARE TOOL domain, medication and food review. LPA Calderon met with House Lead Manager Derry Samdijam and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory clients ages 18-59. The facility is operating within the scope of its license, 1 client over 59 years of age.

A tour of the single-story facility included the 4 client bedrooms, 2 client bathroom, kitchen, dining area, living room, laundry area, front yard and backyard and attached garage.

LPA conducted the tour with House Lead and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept locked and inaccessible to clients in care. Cleaning chemicals are kept locked and kept in room in kitchen area. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Medications are kept locked in a dining area cabinet medication was checked for 3 clients and no deficiencies noted. Client files are kept locked in medication cabinet and staff files are on an online portal, all documentation's are present and staff are cleared. Two clients have a restricted health condition plan in place.Clean towels and extra clean linen were observed in a hallway cabinet. Dining and living room have sufficient lighting and sitting area. All bedrooms have all required furniture, lighting, and bedding, there is a resident with half bed rails and a physician order in place. The bathrooms were observed with shower mats and grab bars for non-ambulatory clients. The water temperature was tested in the both bathrooms and measured within the required 105-120 degrees F. Fire extinguisher were observed in the kitchen, and are fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. The carbon monoxide was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
(CONTINUATION TO LIC 809-C)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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: NURTURE HOME CARE
FACILITY NUMBER: 198603237
VISIT DATE: 12/08/2023
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Administration certification expires: 6/8/2024

Fire Drill Date: 12/5/23

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided via email.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC809 (FAS) - (06/04)
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