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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603349
Report Date: 09/09/2021
Date Signed: 09/09/2021 01:32:00 PM

Document Has Been Signed on 09/09/2021 01:32 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:EDWARD'S COVEFACILITY NUMBER:
198603349
ADMINISTRATOR:CRUZ, EDWARD E.FACILITY TYPE:
735
ADDRESS:11954 166TH STREETTELEPHONE:
(714) 659-9152
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 3CENSUS: 0DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Edward CruzTIME COMPLETED:
01:45 PM
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On 9/9/2021 Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan conducted an unannounced annual visit. LPAs met with administrator, Edward Cruz and stated the purpose of the visit. Currently there are no clients in care. Facility is licensed to serve Adults ages 18-59. The facility obtained a fire clearance for a capacity of 3 Ambulatory clients only. LPAs observed Covid-19 Postings on the front door
and throughout the facility. There was hand sanitizer available for use throughout the facility as well.

There are 3 bedrooms and 2 bathrooms: 2 bedrooms designated for clients and one bedroom for staff. There is a small family room upon entry, a living room, dining area, and the kitchen. There are fire extinguishers are located in kitchen and in small family room near entry, both fire extinguishers are properly charged. All beds have the required linens and have mattresses in good repair. The bedrooms are equipped with the required furniture. Extra linens, blankets, towels, and personal hygiene supplies were observed. All trash cans have tight, fitted covers. The refrigerator is operating properly at the recommended settings. LPAs observed at least 2 days of perishable foods and a minimum of 7 days of nonperishable items for all clients. LPAs observed the knives located in the kitchen cabinet and accessible through a safety latch. The medications and client files will be locked in the metal drawer located in the living room. LPA observed the use of video surveillance in the facility and per Licensee they are used in the common area which oversee the living room, kitchen, and front door. There is a functional wall mounted heater located in the living room, next to the bathroom. LPAs tested water temperature in shared bathroom, water temperature was measured at 120 degrees Fahrenheit.


CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: EDWARD'S COVE
FACILITY NUMBER: 198603349
VISIT DATE: 09/09/2021
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Exterior: All passageway and doors are free of obstruction. The home does not have a pool or any large bodies of water. Window screens are in good repair. There are no security bars on the windows. There is a covered backyard. The washer and dryer is located in the backyard. There is a storage room in the back where the detergent and soap are locked in a cabinet. LPAs observed another stove next to the dryer and per Licensee, only the oven is used. There is a large countertop in the middle of the backyard with a functional stove. The stove top has a wooden cover place over it for safety when not in use. LPAs observed an electric saw, an electric wok for cooking and gardening tools in the backyard area which were removed at time of visit and make inaccessible to clients in care, LPAs are issuing a Technical Violation for there were no clients in care at time of visit.

Due to no clients in care, LPAs were not able to review medication.

Exit Interview conducted, a copy of report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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