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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603349
Report Date: 11/04/2022
Date Signed: 11/04/2022 09:25:52 AM

Document Has Been Signed on 11/04/2022 09:25 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: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:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Edward Cruz - LicenseeTIME COMPLETED:
09:30 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 Edward Cruz - Licensee and explained the reason for the visit. The facility is licensed to serve 3 ambulatory only clients ages 18-59. Facility currently has no clients.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the office room, kitchen, dining area, living room, 2 client bedrooms, 2 bathrooms, front yard and backyard.
LPA Mora conducted the tour with Edward Cruz 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 in a kitchen cabinet. Chemical and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept locked 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 walking closet. Dining and living room have sufficient lighting and sitting area. Medications will be kept locked in a cabinet in the living room. Client and staff files will also be kept locked in the medication cabinet. All bedrooms have all required furniture, lighting, and bedding. The client bathroom was observed with shower mats. The water temperature was tested in both bathrooms and measured at 110.4 degrees F and 108.9 degrees F, which is not within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed in each bedroom and throughout the facility and were operable during the visit. A carbon monoxide was observed in the living 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.

There are no client medication and files to review. LPA reviewed files for 2 staff and observed no deficiencies. LPA observed administrator certificate for Edward Cruz - 6044600735 with an expiration date of 06/05/2023.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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: EDWARD'S COVE
FACILITY NUMBER: 198603349
VISIT DATE: 11/04/2022
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Facility has 30 days supplies of Personal Protective Equipment. 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: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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