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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603410
Report Date: 05/27/2022
Date Signed: 05/27/2022 05:24:41 PM


Document Has Been Signed on 05/27/2022 05:24 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: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:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Humberto Santamaria
Staff, Noemi Pardomartinez and
Assistant Administrator, Carmen Santamaria 		TIME COMPLETED:
05:00 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) Tao conducted an unannounced annual inspection visit. LPA met with Staff, Noemi Pradomartinez, Administrator, Humberto Santamaria, and Assistant Administrator, Carmen Santamaria, who assisted with the visit Facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above. Facility has approved for six (6) hospice waivers. Annual licensing fees are current. Administrator certificate is current and the expiration date is 12/21/23.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



This facility is located in a residential neighborhood, single story house. Facility consisted of five (5) resident bedrooms, two (2) bathrooms, one (1) staff room/office, living room, TV room, dining room, garage with laundry area, kitchen, and backyard with patio. All residents' rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature measured at 110.7 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers’ last service is 4/25/22 and are fully charged.

(- continued in LIC 809C -)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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 2


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: 05/27/2022
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
26
27
28
29
30
31
32
The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked closet and inaccessible to residents. Resident records are stored, locked and inaccessible to residents. Toxic substances are inaccessible to residents.

No deficiencies were observed and cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with Administrator, Humberto Santamaria
and Assistant Administrator, Carmen Santamaria . Administrator's signature on this form confirm receipt of these documents. A copy of LIC 809s report were provided.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2