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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603427
Report Date: 06/19/2023
Date Signed: 06/19/2023 11:25:15 AM

Document Has Been Signed on 06/19/2023 11:25 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HORST HOME CAREFACILITY NUMBER:
198603427
ADMINISTRATOR:ANSELMO, YETZIRAFACILITY TYPE:
735
ADDRESS:19518 HORST AVETELEPHONE:
(562) 215-3265
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 4DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Administrator Yetzira AnselmoTIME COMPLETED:
11:40 AM
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On 6/19/23 at 8:25 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Horst Home Care. Upon arrival LPA was greeted by Direct Support Professional (DSP) Elizabeth Berumen who contacted the Administrator, Yetzira Anselmo, at 8:32 a.m. to assist with today's visit. This home is licensed to serve age range 18 through 59. 1 Ambulatory and 3 Non-Ambulatory of which 1 may be bedridden. Rooms 3 & 5 Non-Ambulatory, and room 4 bedridden. The is a level 4I home and the vendor is Harbor Regional Center. There were (4) clients in care during the time of this visit. All four (4) clients are no verbal. LPA was unable to interview clients due to limited communication. The last emergency disaster/fire drill was conducted on 5/18/2023. The Administrator Certificate expires on 6/03/2023 #6044039735. LPA verified Administrator certificate is currently on the active list. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (4) client files, medications, and medication administration records for (4) clients and P&I.

This home contains 4 bedrooms, 1 staff bedroom, 3 bathrooms, living room, office, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The three bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 109.5*F-111.3*F. The smoke detectors were battery operated, tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (3) fire extinguishers located in kitchen, dining room and garage fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. Cleaning agents and toxins was secured and locked underneath kitchen sink. Knives and sharps locked in kitchen drawer.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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: HORST HOME CARE
FACILITY NUMBER: 198603427
VISIT DATE: 06/19/2023
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The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.

The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The living room contained board games and activity supplies available to the clients. In addition, a working fireplace contained a covered screen so that it was inaccessible to the clients.

The office contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

Exit interview conducted with Yetzira Anselmo, Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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