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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603620
Report Date: 04/10/2023
Date Signed: 04/10/2023 05:29:17 PM

Document Has Been Signed on 04/10/2023 05:29 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 AFACILITY NUMBER:
198603620
ADMINISTRATOR:GONZALEZ, DIANAFACILITY TYPE:
735
ADDRESS:9937 EMERADO DRIVETELEPHONE:
(562) 536-2935
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 4CENSUS: 0DATE:
04/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Appliant Jesse Quezada TIME COMPLETED:
10:15 AM
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Licensing Program Analysts (LPA's) Jose Villalobos, Tena Herrera and Erik Zaragoza conducted an announced visit with Applicants Diana Gonzalez and Jesse Quezada. The purpose of the visit was to conduct the Pre-Licensing visit.

An application was submitted to CCLD on 11/15/2022, for an Initial License of a Adult Residential Facility for ages 18-59 . The requested capacity of 4 clients, (4) ambulatory, (0) non-ambulatory and (0) may be bedridden.

Structure/Physical Plant:
The facility is part of a single story home located in a residential area and contains the following: living room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage space for medications and sharps, (4) client rooms, (3) bathrooms for clients; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for client use, area for washer and dryer. The residence is equipped with central air and heating.

Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: Bedrooms #1-#4 are for (1) ambulatory client each.. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: Bathroom #3 is attached to bedroom #3. All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. 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 (1) cordless phone for residents use. Fire Extinguisher 1 and 2 fully charged and up to date..

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 A
FACILITY NUMBER: 198603620
VISIT DATE: 04/10/2023
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 Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates are stored at the other location until residents move in. Knives, cutlery and other sharps inaccessible to residents will be kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working. Smoke detectors and also carbon monoxide detectors observed, all detectors tested and operational. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured within title 22 regulations. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to residents. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, which is available for staff use. Residents & Staff Files: Facility has a locked cabinet for resident and staff files. Sample files were observed. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 11/17/22.

Component III:
Applicants wished to waive component III as it was conducted on 2/23/23 for facility #198603619.

The following Corrections need to be made prior to clearing the physical plant:
  • Required postings such as: Emergency disaster plan, activities calendar, food menu, clients personal rights

  • Backyard has a gate with no lock that leads to a downhill slope which could be a potential health and safety risk

  • inoperable go kart located in the backyard to be removed

  • telephone line to be operable

LPA to return on another day to observe corrections. An exit interview was conducted and a copy of this report has been furnished to the Applicants. 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: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC809 (FAS) - (06/04)
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