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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603623
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:16:44 PM


Document Has Been Signed on 02/02/2023 01:16 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 IIIFACILITY NUMBER:
198603623
ADMINISTRATOR:BISNAR, LOURDESFACILITY TYPE:
740
ADDRESS:11511 THOMAS PLACETELEPHONE:
(562) 864-6308
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 4DATE:
02/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Lourdes Bisnar - Applicant
Edjeska Macandili - Applicant		TIME COMPLETED:
01:30 PM
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Licensing Program Analyst(s) (LPA) Mary Flores and Ashley Calderon conducted an announced pre-licensing visit at the location. LPA Flores met with Edjeska Macandili Applicant and Lourdes Bisnar staff.

The home was approved by the Fire department on 12/8/22 for 5 non-ambulatory residents and 1 bedridden resident (in bedroom #4) over the age of 60. The location is a single home in a residential area and consist of a kitchen, a living room, a dining area, 4 resident bedrooms, 2 bathrooms, an attached garage, a front yard, and a back yard.
LPAs conducted a tour of the facility with Edjeska Macandili and Lourdes Bisnar applicant(s) and observed the following:
Living room has sufficient sitting area. Dining room has a covered fireplace. Kitchen is clean and knives are stored in a locked drawer. A cabinet with emergency food supplies is located next to the refrigerator. Refrigerator's temperature read at 40 degrees F. All bedrooms have sufficient lighting, furniture, and bedding supplies. Bathrooms were observed clean, and in working condition. Bathroom #1 was observed to have a skid mat, and the required grab bars, water temperature was tested at 117.5 degrees F., and bathroom #2 has a shower that is not used by the residents and water temperature was tested at 117.0 degrees F., which is within the required 105-120 degrees F. Additional linens were observed, hygiene products for each resident were observed. The home does not have large bodies of water. A shaded sitting area is provided in the backyard. Each exit door has an auditory device in working condition. Home is in good repair indoor and outdoor. Laundry is located in the attached garage and cleaning supplies are maintain in a locked cabinet. Home does not prepare meals and does not maintain food supplies. The applicant will submit a food waiver request as part of their plan of operation to Centralized Application Bureau to allow the home to prepare meals outside of the home and brought to serve at the home. Files for 4 residents and 3 staff were reviewed.
Component III was conducted during this visit.
The home meets Title 22 Regulations at this time.
Exit interview was conducted with Lourdes Bisnar applicant and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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