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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603593
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:04:55 PM

Document Has Been Signed on 10/21/2022 12:04 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:VALLEY STAR RANCHO LOS AMIGOS CRTFACILITY NUMBER:
198603593
ADMINISTRATOR:HONORE-HARRELL, ALISHAFACILITY TYPE:
772
ADDRESS:7735 LEEDS STTELEPHONE:
(562) 719-2865
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 16CENSUS: 0DATE:
10/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alisha Honore-Harrell
TIME COMPLETED:
12:15 PM
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Licensing Program Analyst, (LPA) Angelica Rea conducted an announced visit to this location, for the purpose of conducting a pre-licensing visit and component III. On today's visit, LPA was greeted by Administrator, Alisha Honore- Harrell, who allowed entry into the facility. Also present on today's visit was Regional Administrator, Stephen Albrecht, Head maintence person, Nicholas Ruguone, and Marianne Sharon MHS II. LPA was assessed per covid protocol prior to entering the facility.

LPA Rea toured facility with Administrator and team. Facility consists of 2 stories, with a reception, lobby area, laundry room with washer and dryer, with detergent(s) locked in cabinet, hygiene supplies located in hygiene room, nurse assessment room, food storage room, medication room with first aid kit and first aid handbook observed, living room/visiting room, kitchen, appliances are operational, janitors closet, where toxins will be locked, living room/visiting room, computer areas, multipurpose room, dining area, lounge area, and staff offices. There are a total of 6 restrooms for resident use, 3 on each floor. There are 2 restrooms for staff use, one on each floor. Bedrooms for Residents: Bedrooms are equipped with a bed, bedframes, dresser, lamps, chairs and adequate closet space. There is adequate lighting throughout the room. LPA observed signal system, tested and operational. Smoke detector/carbon monoxide was tested and operational, water temperature measured at 109.2 degrees Fahrenheit. The facility has central air and heat. The temperature was comfortable at the time of the visit.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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: VALLEY STAR RANCHO LOS AMIGOS CRT
FACILITY NUMBER: 198603593
VISIT DATE: 10/21/2022
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Walls, floors, ceilings were observed to be clean and sanitary throughout the building. There are no obstructions to the walkways and/or driveways. There are no pools or bodies of water at the facility. The facility has an elevator, which is operational.

Facility van was observed, there is a maintenance log which will serve to ensure the vehicle is properly maintained in safe operating condition. The outdoor grounds were toured and observed to be free of debris, obstructions, or hazards. There was a designated shaded patio area with table and chairs accessible for resident use. Staff and Residents files will be stored and maintained at the facility. The emergency phone numbers and exit plan are available in the hallways. The menu is posted in the dining area.

Physical plant met title 22 requirements. Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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