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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603502
Report Date: 09/06/2024
Date Signed: 09/06/2024 01:55:25 PM

Document Has Been Signed on 09/06/2024 01:55 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA MARIPOSA - PREMIEREFACILITY NUMBER:
198603502
ADMINISTRATOR/
DIRECTOR:		DANIELS, VANESSAFACILITY TYPE:
735
ADDRESS:6048 PREMIERE AVE.TELEPHONE:
(562) 353-7275
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:01 AM
MET WITH:DSP Kayla LevineTIME VISIT/
INSPECTION COMPLETED:
02:05 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) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Kayla Levine at approximately 11:00 AM and explained reason for visit. Administrator Vanessa Daniels was notified by telephone.

The facility is licensed to serve 3 ambulatory and 1 non-ambulatory clients ages 18-59. Facility currently has 3 ambulatory and 1 non-ambulatory client serviced by Harbor Regional Center. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, kitchen, 4 client bedrooms, 2 bathrooms, laundry area, front yard, backyard, and detached garage.

LPA toured the facility and observed the following: Each client bedroom has the required bedding. Three (3) out of four (4) bedrooms were missing chairs TV given. There is extra clean linen and towels in each clients closet. Smoke detectors and carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has two (2) fully charged fire extinguishers which is kept in kitchen and living room. Cleaning supplies and toxic substances are inaccessible to clients in a locked cabinet in laundry room. Sharps and knives are locked in cupboard in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There is an extra freezer and refrigerator in garage with more food. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 4
Document Has Been Signed on 09/06/2024 01:55 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/06/2024 at 01:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA MARIPOSA - PREMIERE
FACILITY NUMBER: 198603502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above Administrator file was inaccessible at time of annual inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
1
2
3
4
Administrator will emaill file to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CASA MARIPOSA - PREMIERE
FACILITY NUMBER: 198603502
VISIT DATE: 09/06/2024
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
Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Administrator file was not accessible deficiency cited. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in August of 2024. Infectious control plan was reviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4