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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603455
Report Date: 06/01/2023
Date Signed: 06/02/2023 10:42:12 AM

Document Has Been Signed on 06/02/2023 10:42 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:MIRADA CRESTFACILITY NUMBER:
198603455
ADMINISTRATOR:TORRES, PRINCESS WILYNFACILITY TYPE:
735
ADDRESS:14428 SAN DIEGUITO DR.TELEPHONE:
(424) 362-6566
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 4DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Assistant Administrator Derry SandajanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. On today’s visit LPA met with Assistant Administrator Derry Sandajan and the purpose of the visit was discussed. Administrator Princess Torres arrived shortly after.

As a part of the inspection, LPA used the inspection tool, reviewed (4) client records, (4) staff files, and (4) client medications. Currently the facility has (4) clients which are ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. The facility is a single story building located in a residential area and contains the following: dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for sharps, (3) client rooms, (1) bedroom for live in staff, (2) bathrooms with shower, toilet and washbasin, and space for washer and dryer. Backyard also has a shaded area and seating for client use. There is a detached garage in the backyard kept inaccessible to clients. There is a pool in the backyard fenced in and kept locked and inaccessible to clients. The residence is equipped with central air and heating. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#3 are equipped with a beds each, a dresser, lamp, chair, overhead lightning and closet space. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored in each client's bedrooms were observed. Fire alarms are interconnected and operational. Required postings observed. Plan of Operation and Emergency disaster plan reviewed. Water temperature within required tittle 22 regulations. Care Tool was completed and based on Title 22 Regulations, no Deficiencies will be documented.

An exit interview was conducted and a copy of today's report was provided and discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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