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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603347
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:14:56 AM

Document Has Been Signed on 06/20/2024 11:14 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:PHILADELPHIAN HOMEFACILITY NUMBER:
198603347
ADMINISTRATOR/
DIRECTOR:
RESURRECCION, LEANDROFACILITY TYPE:
735
ADDRESS:5856 PEARCE AVENUETELEPHONE:
(562) 732-7514
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 4DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:31 AM
MET WITH:Marie Resurreccion (Assistant Administrator) TIME VISIT/
INSPECTION COMPLETED:
11:29 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Marie Resurreccion (Assistant Administrator) and explained the reason for the visit. The facility is licensed to serve 4 ambulatory, of which 2 may be non-ambulatory clients in the age range 18 of through 59. Facility is approved for 2 hospice waivers. The facility is operating within the scope of its license.

A tour of the single-story facility included the living room, dining room, kitchen, office room, 4 client bedrooms, 2 client bathrooms, laundry room, staff room, front yard, backyard, and detached garage. LPA Mora conducted the tour with Leandro Resurreccion 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 were observed locked under the kitchen sink. Chemical and cleaning solutions are kept locked in a kitchen cabinet. The First Aid kit is kept in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are centrally stored in a locked office cabinet. Client and staff files are kept locked in an office room cabinet. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 107.8 degrees F and 109.6 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. There are four carbon monoxides located in the kitchen, hallway, laundry area and office room. 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. LPA reviewed medication for 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 clients and 5 staff. LPA reviewed P&I funds for all 4 clients with staff present. Emergency Disaster Plan was reviewed. LPA observed administrator certificate for Leandro Resurreccion - 6051402735 with an expiration date of 03/11/2025.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were 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: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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