198603410-5-6-2021-28-AS-LMAZ-C2RNU9-20210506104557

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603410
Report Date: 03/24/2021
Date Signed: 05/06/2021 10:46:16 AM

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:	LA CASITA RESIDENTIAL CARE INC.		FACILITY NUMBER:	198603410
ADMINISTRATOR:	SANTAMARIA, HUMBERTO		FACILITY TYPE:	740
ADDRESS:	700 N. GRAND AVE.		TELEPHONE:	(626) 387-9987
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91741
CAPACITY:	6	CENSUS: 6	DATE:	03/24/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Humberto Santamaria		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Linda Almaraz conducted a pre licensing tele-visit due to a change of ownership name. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this pre licensing visit was conducted telephonically with applicant Mr. Santamaria and later on Mrs.Santamaria arrived. A component III is required and will be conducted on 3/25/21 due to an emergency the applicant had. There are currently 6 residents living in the facility. The fire clearance has been approved for 6 non-ambulatory residents. The physical plant was toured and the following was observed. This facility is located in a residential neighborhood, single story house, with a small ramp entrance that leads to the front door and it contains (6) bedroom(s), (2) bathrooms, (2) living rooms, dining area, garage with laundry room, food pantry and kitchen. The fire alarms, smoke alarms and carbon monoxide detectors were tested and operate properly. All appliances in the kitchen were observed to be clean and operational. Sharp objects such as knives are stored in a locked kitchen cabinet. Their fire extinguisher is located by the food pantry. All cleaning solutions and chemicals are locked and stored in the garage. The washer and dryer are located in the garage. Resident and staff files are located in a locked hallway closet along with medications and first aid kit. There is a fireplace located in the front living room which is covered by a locked screen fence. Dining room has a table and six chairs. Resident rooms were observed to have furniture such as bed frames, dressers and sufficient closet space. Bedrooms also have the required bedding sheets. There are no staff bedrooms. The residents bathroom have the required grab bars in the shower and near the toilets. The hot water temperature tested at 112.6 degrees F*, which is within the required 105 - 120 degrees. There is sufficient lighting throughout the home. Window and window screens are in good repair. There are no security bars on the windows. The backyard has a shaded patio area with patio furniture. There is a gate outside the perimeter of the property. The administrator reports there are no guns or weapons in the home. (Continued on a LIC 809-C)

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

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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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: LA CASITA RESIDENTIAL CARE INC.	FACILITY NUMBER: 198603410
	VISIT DATE: 03/24/2021

NARRATIVE

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The following is required prior to licensure;

Remove construction material and hazards from passageways in the yard
Night stands for room #2
Chairs for room #2
Remove bed rails from beds
Remove additional beds in single rooms
Trash can lid for resident bathroom
Separate residents toothbrush in bathroom
Separate and ensure residents have their own towels
Needed Hygiene supply: toothpaste and deodorant
First Aid Manual
7 day supply of non-perishables available
Signs: Post Let Us No sign , Resident and Family counsel, Ombudsman, Emergency disaster plan, Personal rights and complaint procedures, labor information required by law, Theft and Loss policy, Emergency exiting plan and telephone numbers
Food menu available
Copy of Liability insurance

Applicant shall submit receipts and pictures to LPA as proof of correction via email/fax by 4/7/2021.

A telephonic exit interview was conducted with Applicant and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

LIC809 (FAS) - (06/04)

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