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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603613
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:07:56 PM

Document Has Been Signed on 01/12/2023 02:07 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:STAR VIEW RANCHO LOS AMIGOS CRTFACILITY NUMBER:
198603613
ADMINISTRATOR:LOZANO, AIDA YVONNEFACILITY TYPE:
772
ADDRESS:7755 LEEDS STREETTELEPHONE:
(562) 719-2867
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 16CENSUS: 0DATE:
01/12/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Applicant Yvonne Lozano TIME COMPLETED:
11:15 AM
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Licensing Program Analyst, (LPA) Jose Villalobos conducted an announced visit to this location, for the purpose of conducting a pre-licensing visit. On today's visit, LPA was greeted by Applicant Yvonne Lozano who allowed entry into the facility.

An application was submitted to CCLD on 8/17/2022, for an Initial License of a Social Rehabilitation Facility. The requested capacity of sixteen (16) clients, of which zero (0) may be non-ambulatory and zero (0) bedridden.

Structure/Physical Plant:
Facility is a two-story building with a reception, lobby area, laundry room with washer and dryer on both floors, he facility has central air and heating, hygiene room, nurse assessment room, food storage room, medication room for storing and locking medications, living room/visiting rooms, kitchen, janitors closet, Large Storage room, living room/visiting room, computer areas, multipurpose room, dining area, lounge area, staff office, staff lounge, employee patio area, (2) staff stations (1) on each floor. 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

Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: Bedrooms #1-#8 are for (2) ambulatory clients each.. All bedrooms are equipped with: overhead lighting, (2) chairs, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: Client Bathroom #1-8 observed. (4) of (8) restrooms have the shower in a separate room from the toilet. There are (2) restrooms designated for staff use. Restrooms have a working toilet, wash basin, shower, grab bars and nonskid mats.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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: STAR VIEW RANCHO LOS AMIGOS CRT
FACILITY NUMBER: 198603613
VISIT DATE: 01/12/2023
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Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There are (2) cordless phone for client use. Fire Extinguisher observed Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates are stored at the other location until residents move in. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Smoke detectors and also carbon monoxide detectors observed, all detectors tested and operational. Appliances: Refrigerators, dish washer, laundry appliances, Microwave, observed and operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -120 degrees all around the building. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to clients. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, which is available for staff use. Clients & Staff Files: Facility has a locked cabinet for client and staff files. Sample files were observed. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 9/21/22.

There are no corrections needed and physical plant is cleared.

Component III:
Component III was conducted at the time of this visit with Applicant Yvonne Lozano

An exit interview was conducted and a copy of this report has been furnished to the Applicant Yvonne Lozano. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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