<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603410
Report Date: 05/03/2021
Date Signed: 05/06/2021 10:37:43 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, HUMBERTOFACILITY TYPE:
740
ADDRESS:700 N. GRAND AVE.TELEPHONE:
(626) 387-9987
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 6DATE:
05/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Administrator, Humberto SantamariaTIME COMPLETED:
11:15 AM
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 subsequent pre licensing visit due to pending pre-licensing corrections. 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 Humberto Santamaria and Carmen.Santamaria.

On 4/8/2021, the physical plant was toured and the following was observed.
  • Construction material and hazards from passageways in the yard were removed
  • Obtained night stands and chairs for room #2
  • Removed additional beds in single rooms
  • Obtained trash can lid for residents bathroom
  • Separated residents toothbrush in bathroom
  • Obtained individual towels for residents
  • Obtained toothpaste and deodorant for residents
  • Obtained 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, Emergency exiting plan and telephone numbers were obtained and posted
  • Food menu available
On 4/30/2021, the following items were sent via email to LPA
  • Theft and Loss policy
  • Copy of Liability insurance
  • Hospice orders for hospital beds with half rails

A telephonic exit interview was conducted with Applicant and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
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 1