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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603619
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:07:37 PM

Document Has Been Signed on 02/23/2023 01:07 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:DAJAH'S HOME BFACILITY NUMBER:
198603619
ADMINISTRATOR:ROBERTSON, MILESFACILITY TYPE:
735
ADDRESS:11624 TIGRINA AVETELEPHONE:
(562) 755-7464
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 4CENSUS: 0DATE:
02/23/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jesse Quezada TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Angelica Rea, conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. Also present was Diana Gonzalez, House Manager. An application was submitted to CCLD on 05/05/2022, for Initial license for a Adult Residential Facility to serve age range 18 through 59. The requested capacity is for 4 ambulatory residents.

The facility is a single story 4 bedroom, 2 bathroom home located in a residential neighborhood.
LPA observed the following: The bedroom(s) have beds, including, blankets, sheets, mattress pads, bedspreads/comforters. There is sufficient light for reading, with ample storage space. LPA viewed the following will be locked and inaccessible; medications, hygiene supplies, cleaning solutions, toxins, knives, staff and client files, and client P & I. Kitchen has necessary supplies and equipment, including refrigerator, stove, dishwasher, microwave, pots/pans, utensils, cups, plates. The bathroom was reviewed and found to meet regulations. Hot water temperature measured at 112.2 degrees F. The dining and living room have adequate seating space. Garage has a laundry area, which has working washer and dryer. Sufficient hygiene & linen supplies were observed. All exits and passageways are free of obstructions. LPA viewed first aid kit, and fire extinguisher. Smoke detector(s)/ Carbon Monoxide detector(s) were tested and found to be operational. Licensee reports no guns or weapons in the home. There are no bodies of water. Backyard has a covered patio and patio furniture. Emergency disaster plan, personal rights, emergency phone numbers, and complaint procedures were observed to be posted in the entry way.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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: DAJAH'S HOME B
FACILITY NUMBER: 198603619
VISIT DATE: 02/23/2023
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A current disaster and mass casualty plan is maintained at the facility. An operating telephone was observed on the premises (562) 245 -6030, which is easily accessible and available for client use. Labor poster, is posted in garage.

The following physical plant items are needed prior to licensure:

1.) Room #2 needs window coverings
2.) Room #2 needs a dresser

Licensee will contact LPA Rea once the physical plant is ready and corrections have been made.

Exit interview conducted, and a copy of report was provided to Mr. Quezada.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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