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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603620
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:31:47 AM

Document Has Been Signed on 02/13/2024 11:31 AM - 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:
02/13/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jesse QuezadaTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Licensee Jesse Quezada. The purpose of the visit was to conduct the Annual Inspection.

License was granted 05/08/2023 for an Adult Residential Facility for ages 18-59 . Capacity of 4 clients, (4) ambulatory, (0) non-ambulatory and (0) may be bedridden.
Currently the facility has 0 clients and is vendorized by ELAC.

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.

Annual Inspection was completed which includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights- Information, Client records- Incident Reports, Food Service, Health related services, Incidental Medical Services, and Disaster Preparedness.

No deficiencies.

Exit interview completed with Licensee Jesse Quezada
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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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