198603563-9-2-2022-28-AS-BTAO-CHVQQR-20220902122246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603563
Report Date: 09/02/2022
Date Signed: 09/02/2022 12:22:59 PM

Document Has Been Signed on 09/02/2022 12:22 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:	TELECARE CITRUS HOUSE		FACILITY NUMBER:	198603563
ADMINISTRATOR:	TBH		FACILITY TYPE:	772
ADDRESS:	7725 LEEDS STREET		TELEPHONE:	(925) 250-5288
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY: 16		CENSUS: 0	DATE:	09/02/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Bryan Sawlsville, Administrator		TIME COMPLETED:	12:45 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) Tao, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA met with Bryan Sawlsville, Applicant, who assisted with the visit. Currently, facility has not admitted any resident. An application was submitted to CCLD on 05/02/22. It is an initial application for a Social Rehabilitation Facility (SRF) to serve adults and elderly. The requested capacity is sixteen (16). Fire clearance for capacity of sixteen (16) was granted on 06/15/2022. Structure: Facility has two floors. First floor consisted of two (2) resident bedrooms, four (4) bathrooms, administrator office, receptionist, lobby, residents’ group room, multi - purpose room, living room, kitchen, janitorial room, and laundry room. Second floor consisted of six (6) resident bedrooms, four (4) bathrooms, staff office, staff lounge, lactation room, living room, storage, janitorial room, and laundry room. There is a elevator located at the lobby. No bodies of water or pool at the premises. No firearm at the building. Passageways, walkways, driveways, steps and stairways are free from obstructions. Signal system: Signal system is installed on both floors and operable. Bedrooms Residents: Bedrooms for residents are furnished and in compliance with regulations. The resident bedrooms are spacious and will easily accommodate the resident’s furnishings.( - continued in LIC 809 C - )

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TELECARE CITRUS HOUSE	FACILITY NUMBER: 198603563
	VISIT DATE: 09/02/2022

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, and shower areas. Shower areas have non-skid mats and grab bar.

Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review at the entrance and receptionist desks. Fire Extinguishers are located at hallways, mounted on the wall. Last service was 06/20/22.

Smoke Detectors:
Carbon monoxide detectors and smoke detectors are operable. Smoke detectors are hard wired.

Appliances:
Microwave, washer, and dryer are operable. Refrigerator in the kitchen has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat and each resident’s bedroom is individually climate controlled.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in locked drawers near the sink. Food supply adequate stored and maintained the required non- perishable and perishable food supply at the facility. Dishwasher in kitchen was properly installed and functioning.

Toxins:
All cleaning compounds, poisons and toxins are stored and inaccessible to residents.
( - continued in LIC 809 C - )

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TELECARE CITRUS HOUSE	FACILITY NUMBER: 198603563
	VISIT DATE: 09/02/2022

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Water Temperature:
Tested at 116.5 degrees Fahrenheit and in compliance.

Medications and Resident records:
Medication cabinet and resident records cabinets are locked and available to staff but inaccessible to residents. First aid kits had been inspected which have at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual. They are stored in administrator office and receptionist which are available for staff use but inaccessible to residents.

No issues were observed during the visit.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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