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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603293
Report Date: 05/25/2021
Date Signed: 05/25/2021 03:46:51 PM

Document Has Been Signed on 05/25/2021 03:46 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:ORANGE GROVE RESIDENTIAL CAREFACILITY NUMBER:
198603293
ADMINISTRATOR:POLLARD, TOMEIKOFACILITY TYPE:
735
ADDRESS:1775 ORANGE GROVE AVETELEPHONE:
(323) 707-0053
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 4CENSUS: 0DATE:
05/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Myaluisa and Nahivic Echenique AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Licensee Myaluisa and Nahivic Echenique Administrator and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Licensee Mya Luisa and Nahivic Echenique Administrator 5/25/2021 at 11:00 AM and the following was observed:
Facility contains 3 Bedrooms and 2 Bathrooms, dining room, living room, TV room, and activity room.
Required Annual inspection included Infection Control Domain and check of the food supply, medications and criminal clearance check.
All staff were cleared and associated. 30 day supply of medication on hand.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Temperature checks are conducted 2x a day and logged.
Staff have been trained in hand washing.
Staff are sufficient with no shortages and there is a plan to replace workers if ill.
There are rooms available if isolation is needed. Staff wear masks, gloves and face shields.
Bathrooms have proper signage for hand washing. There are multiple stations for hand sanitizing.
Social distancing is implemented. Meal times are sanitized after each meal.
Facility has sufficient supply of PPE. Facility has a specific plan to ensure proper cleaning and disinfection of environmental surfaces and laundry; commonly touched surfaces are cleaned and disinfected at least once every shift . Plan when to notify medical provider if symptoms develop or COVID-19 exposure or when to call 911 for severe respiratory distress. Advisory notices issued (LIC 9102.)
Exit interview conducted with Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2021
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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