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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603245
Report Date: 12/09/2022
Date Signed: 12/09/2022 10:40:24 AM

Document Has Been Signed on 12/09/2022 10:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA MARIPOSA-DOLLARFACILITY NUMBER:
198603245
ADMINISTRATOR:DANIELS, VANESSA R.FACILITY TYPE:
735
ADDRESS:2403 DOLLAR STREETTELEPHONE:
(562) 788-7192
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 4DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Vanessa Daniels - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Vanessa Daniels (Administrator) and explained the reason for the visit. The facility is licensed to serve 1 ambulatory and 3 non-ambulatory only clients ages 18-59. The facility is operating within the scope of its license.

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

LPA Mora conducted the tour with Vanessa 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 under the kitchen sink. Cleaning chemicals are kept locked in a hallway closet. 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 hallway cabinet. Client and staff files are kept in the garage. 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. 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 at 116 degrees F and 116.3 degrees F, which is within the required 105-120 degrees F. Fire extinguisher were observed in the laundry area and hallway, 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 observed in the living room and 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. Medications for all 4 clients was reviewed. Medications are documented properly and given as prescribed. Files for all 4 clients and 5 staff were reviewed. No deficiencies found with the files.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CASA MARIPOSA-DOLLAR
FACILITY NUMBER: 198603245
VISIT DATE: 12/09/2022
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Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

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.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
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