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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603510
Report Date: 02/18/2025
Date Signed: 02/18/2025 12:56:30 PM

Document Has Been Signed on 02/18/2025 12:56 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:SSG FLORENCE HOUSEFACILITY NUMBER:
198603510
ADMINISTRATOR/
DIRECTOR:
PARK, JUNEFACILITY TYPE:
772
ADDRESS:8627 JUNIPER STTELEPHONE:
(323) 537-8979
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY: 16CENSUS: 6DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Beltran Chow Program ManagerTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA Program Manager Beltran Chow at approximately 9:50 AM and explained reason for visit.

The facility has fire clearance for a capacity of sixteen (16) clients over the age of 18, two (2) of which may be non-ambulatory. The Facility consist of one structure with eight bedrooms, one dining room, kitchen, two client’s restrooms, one staff restroom, one staff break room, one living room, one storage room, one isolation room, one Janitor room, one reception/waiting room, two therapy room, one staff office, one medication room, one laundry room, one electrical room that is inaccessible to the clients, one staff conference room.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility. The facility has several fully charged fire extinguishers located throughout the facility. Cleaning supplies and toxic substances are inaccessible locked in janitor room and laundry room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of emergency food was observed in kitchen facility has lunch and dinner catered for clients. 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 any swimming pools or large bodies of water. There is a shaded seating area for the residents outside. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SSG FLORENCE HOUSE
FACILITY NUMBER: 198603510
VISIT DATE: 02/18/2025
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Five (5) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Six (6) client files were reviewed and included physicians report, TB clearance, appraisal needs and service plan. Last fire/earthquake drill was conducted on December 10th of 2024. Infectious control plan was reviewed. Two (2) staff and (3) client was interviewed. Client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.

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

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
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