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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603457
Report Date: 07/01/2021
Date Signed: 07/01/2021 11:28:17 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:AYANNA HOME CAREFACILITY NUMBER:
198603457
ADMINISTRATOR:MATE, KELVINFACILITY TYPE:
740
ADDRESS:5602 WHITEWOOD AVETELEPHONE:
(909) 351-6012
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:6CENSUS: 4DATE:
07/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Jiezl Mate - Lead CaregiverTIME COMPLETED:
11:45 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) Mary Flores conducted an unannounced case management visit to follow up on pre-licensing visit conducted on 5/26/21. LPA Flores met with Jiezl Mate - lead caregiver and explained the reason of the visit.

LPA Flores conducted a tour of the facility and observed the previous concerns:
  • Water temperature was tested in bathroom #1 and tested at 108.3 degrees F which is under the required 105 - 120 degrees F.
  • Medication was observed locked.
  • Cleaning supplies and chemicals were observed locked.
  • LPA observed shaded sitting area in the backyard.
  • LPA observed fist aid kit has a tweezer and current first aid manual.
  • LPA observed PRN medications are prescribed by a physician.

Facility will fixed the following items and provide proof of corrections to LPA Mora within 7 days of this visit :

  • Beds in bedrooms #1, #2, #3, #4 were observed and were missing bedding items for each resident.
  • Bed must be removed from back yard, and ensure backyard is clean from cat feces.
  • Applicant will ensure all residents have all the required assessments and documents in resident files. LPA observed resident #1 and #2 were missing required documents in their files. Facility must obtain doctor's request for bed rails for R1. (CONTINUED LIC 809C)
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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 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: AYANNA HOME CARE
FACILITY NUMBER: 198603457
VISIT DATE: 07/01/2021
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
  • Applicant will submit a new LIC 200 and approved fire clearance indicate facility is able to serve 6 non-ambulatory resident, of which 1 may be bedridden.


Exit interview conducted with Kelvin Mate applicant and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2