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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603502
Report Date: 10/14/2021
Date Signed: 10/14/2021 01:48:36 PM

Document Has Been Signed on 10/14/2021 01:48 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:CASA MARIPOSA - PREMIEREFACILITY NUMBER:
198603502
ADMINISTRATOR:DANIELS, VANESSAFACILITY TYPE:
735
ADDRESS:6048 PREMIERE AVE.TELEPHONE:
(562) 353-7275
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 0DATE:
10/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Vanessa Daniels - AdministratorTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an announced pre-licensing visit. LPA met with Vanessa Daniels (Administrator) & Elizabeth Saucier (Assistant Administrator) and explained the reason for the visit.

The home is located in a residential neighborhood in the city of Lakewood and is a one story building which consists of four (4) client bedrooms, two (2) bathrooms, living room, dining room, kitchen, laundry area and a detached garage. The home has a fire clearance from the local Fire Department for a capacity of three (3) ambulatory and one (1) non-ambulatory clients ages 18 - 59.

The following was inspected during the visit with the Administrator and Assistant Administrator: a locked closet in the hallway for central storage of medications, client records, and hygiene products was observed. Cleaning supplies were separate from where food supplies are stored. The walls, ceilings, floors, window screens and areas around the facility were clean and in good repair. A locked storage area under the kitchen sink for cleaning products, disinfectants, and sharps was observed. Two (2) fire extinguishers were observed throughout the facility. Smoke detectors and carbon monoxide detectors were observed throughout the facility which are hardwired and operable. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris. No pools or bodies of water were observed in or around the home. There are no firearms present at the facility.

Required postings were observed to be posted in appropriate places. A current disaster and mass casualty plan is maintained at the facility. Operating telephones were observed in the living room and kitchen, which are easily accessible and available for client use.

(CONTINUED ON 809C)
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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: CASA MARIPOSA - PREMIERE
FACILITY NUMBER: 198603502
VISIT DATE: 10/14/2021
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The first-aid kit was observed and is kept in the hallway closet, which included all required supplies. The refrigerator was observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit.

Food storage and preparation areas, which includes pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwave, refrigerator, and stove were observed to be clean and operating properly. Food utensils were clean and sufficient for the number of clients to be served.



All rooms were observed to be appropriately furnished for their intended use and were client appropriate. The hot water temperature was measured in bathroom #1 and bathroom #2 and measured between 111.2F - 119.1F. The outdoor patio in the backyard was observed to have well shaded area and was furnished for outdoor use. Each clients bedroom was observed to have a mattress, pad, bedsprings, and a pillow which were clean. The client bedrooms have adequate dresser and closet space for clothing and other belongings.

A sufficient supply of linens to permit weekly changing or more often to insure clean linens at all times for clients were observed to be kept in each room's closet. Personal hygiene supplies were observed readily available for client use. Activity supplies were observed and readily available for clients. Employee records will be maintained and locked in the garage.

No outstanding or pending items were observed by LPA requiring additional pre-licensing visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.

Exit interview conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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