198603622-1-26-2023-28-AS-CDCN-CNFTLH-20230126134935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603622
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:49:45 PM

Document Has Been Signed on 01/26/2023 01:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LOVING ARMS RESIDENTIAL CARE FOR SENIOR II		FACILITY NUMBER:	198603622
ADMINISTRATOR:	BISNAR, LOURDES		FACILITY TYPE:	740
ADDRESS:	11507 THOMAS PLACE		TELEPHONE:	(562) 864-6308
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 6	DATE:	01/26/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Lourdes Bisnar, Administrator		TIME COMPLETED:	01:50 PM

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Licensing Program Analyst (LPA) Cynthia Chan conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA met with the applicant, Edjeska Macandili and Administrator, Lourdes Bisnar.

An application was submitted to CCLD for a Change of Ownership of a Residential Care Facility for the Elderly, ages 60 years and older. The fire clearance has been approved for a capacity of 6 residents, which 5 may be non-ambulatory and 1 bedridden. Bedrooms #1,2, and #3 are approved for non-ambulatory; and bedroom #4 is approved for bedridden.

Structure/Physical Plant:

The facility is a single story home with 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, and an attached garage. There are no pool or bodies of water at the premises. There are no items obstructing the hallways or passageways. There is appropriate lighting in the facility and in the rooms. The backyard has a table and chairs for residents use. The facility has auditory devices located by the exit doors and in each of the resident room's sliding doors.

Bedrooms/Bathrooms:
There are a total of 4 bedrooms in the facility. Bedroom #4 is designated as the bedridden room only. The resident rooms have sufficient drawer/closet space, a chair, nightstand, and sufficient lighting.
There are 2 bathrooms. They have the non-skid mats in the tubs/showers and the grab bars. Both bathrooms are clean and sanitary.

Supplies:
There are sufficient supplies of hygiene items such as soap and toilet papers. Extra supplies of clean linens, blankets, fitted sheets, towels are observed. The facility also has adequate supplies of PPE such as gowns, gloves, masks, and hand sanitizers.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LOVING ARMS RESIDENTIAL CARE FOR SENIOR II	FACILITY NUMBER: 198603622
	VISIT DATE: 01/26/2023

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Food Service:
There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. The kitchen is kept clean and sanitary. All the appliances were in working order. Sufficient amount of tableware, dishes, and utensils are observed. The refrigerator is maintained at 40 degrees F or below and the freezer at 0 degrees F or below. The knives and sharps are stored and locked in the kitchen cabinet.

Staff and Residents files:
Staff and Residents files are stored and maintained at the facility. LPA reviewed 6 residents files to ensure all required forms are in their files. The Administrator's certificate expires on 8/9/2024.

Emergency phone numbers, Exit Plan, and Menu: The emergency phone numbers and exit plan are available in the hallways. The fire extinguishers were last inspected on 2/18/22. The facility land line is (562) 864-6308.

Smoke Detectors: The facility has smoke and carbon monoxide combo detectors in each room and in hallways. There is an additional carbon monoxide detector located by the dining room.

Medications, First Aid Kit & Book: Medications are centrally stored and locked inside a closet. The first aid kit contains all the required supplies along with the current first aid manual.

Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies. The required postings such as personal rights, local Ombudsman, and Community Care Licensing LETUSNO are placed at a visible area.

LPA conducted the Component III with the applicant and administrator. The Pre-licensing is complete and the facility has no deficiencies.

An exit interview was held and a copy of this report was given to the applicant.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

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