198603625-2-16-2023-28-AS-ACAN-CP4T7M-20230216132857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603625
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:29:10 PM

Document Has Been Signed on 02/16/2023 01:29 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:	NORA'S RESIDENCE CARE OF CERRITOS		FACILITY NUMBER:	198603625
ADMINISTRATOR:	NORA, PETER		FACILITY TYPE:	740
ADDRESS:	19627 WIERSMA AVE		TELEPHONE:	(714) 322-6480
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	6	CENSUS: 4	DATE:	02/16/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator- Peter Nora		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Calderon and LPA Erik Zaragoza conducted a Pre-licensing for Change of Ownership and Facility Name Change visit, which included Component III orientation. LPA Calderon met with Applicant Peter Nora and owner Euphrosyne Diamaano. LPAs alongside Applicant conducted a walk-through of the entire facility, which included the outside perimeters of the property.The home is located in a residential area within the city limits of Cerritos, CA and consists of a single story building, 5 bedrooms, two bathrooms, a living room, Kitchen/ dining room, and a back yard and an attached garage used for: storage, laundry, overflow of food, and emergency food items inaccessible to residents in care. A facility fire clearance is approved for six (6) non-ambulatory resident’s and of the six, one (1) which can be a bedridden resident, capacity of 6, approved. Bedroom #5 approved for bedridden. Facility will be serving a total capacity of 6, Residential Care for the Elderly and has an approved Dementia care plan. Facility currently has four residents in care, 2 on Hospice. Physical Plant Facility was observed to be clean and in good repair. All window screens were clean and in good repair. There was appropriate lighting in the facility and in each room. Indoor/ outdoor passageways, porch areas were free of obstructions and were free of potential hazard. Ramps were observed to be free of potential hazards. The physical plant is consistent with the submitted facility sketch/floor plan. Continuation on 809C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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: NORA'S RESIDENCE CARE OF CERRITOS	FACILITY NUMBER: 198603625
	VISIT DATE: 02/16/2023

NARRATIVE

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Food Services Area
Kitchen/ dining room were observed to be clean, sanitary and odorless. Trash cans had tight fitting covers.
The food preparations are prepared outside of the home, food wavier request will be submitted to Centralized Application Bureau. Freezer is 0 degrees Fahrenheit and refrigerator is 40 degrees Fahrenheit. A seven day supply of non-perishable foods and 2 day perishable food items were present for the amount of residents to be served, extra refrigerator located in the garage with additional food supply. LPAs observed sufficient tableware, table tops, dishes, and utensils. The facility has at least one dining area and sharp items were observed to be locked and inaccessible. All equipment in good repair.

Records
There is confidential storage area for personnel records, resident records and staff/ administrative files, which will be kept in a locked closed in the activity/office room. LPAs reviewed 5 staff files and 4 resident files for staff and resident preset at the facility during time of visit.

Medications
There is a locked centralized storage for resident medications, which will be kept in a locked cabinet in activity/office room and in same location there is a small refrigerator that remains locked. The first aid kits, was observed by LPAs to include sterile dressings, bandages, thermometer, scissors, tweezers and a facility had a current first aid manual. LPAs reviewed 4 residents medication for residents in care during the time of visit.

Activities
There was activity supplies like color books, board games and puzzles in the activity room, appropriately furnished area such as a living room for residents to entertain friends and guests and relatives.

Bedrooms

Resident bedrooms are large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture, and any resident assistant devices such as wheelchairs
or walkers if necessary. LPAs observed a bed for each resident equipped with good springs, clean and comfortable mattress, appropriate linen, pillow(s) and bedding. All bedrooms were equipped with a chair, night stand, sufficient lighting for each resident. There was sufficient drawer and or closet space for each resident in care. (Continuation on 9099C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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: NORA'S RESIDENCE CARE OF CERRITOS	FACILITY NUMBER: 198603625
	VISIT DATE: 02/16/2023

NARRATIVE

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Bathrooms
Facility has two bathrooms, one for staff and one for residents in care. Bathrooms were observed to be clean, sanitary, operable and odorless. The hot water temperature measured between 105-120 degrees Fahrenheit. Protective devices were observed such as nonskid mat in shower and grab bars in restrooms.

Supplies
LPA observed there to be sufficient supply of hygiene items such as soap, and toilet paper. LPA also observed there to be sufficient supply of clean linen, including blankets, bedspreads, top sheets, bottom sheets, pillow cases, mattress pads, bath towels, hand towels, and wash cloths, to permit changing weekly or more often as needed located in the hallway cabinets.

Miscellaneous
The facility has laundry supplies and equipment, which includes a washer and dryer, located in the garage. There is an operating telephone available for resident use. Emergency lighting supplies e.g., flashlights, batteries were observed. Fire alarms, smoke alarms and carbon monoxide detectors were tested and operate properly. Disinfectants, cleaning solutions, poisons and other items which could pose a danger to residents were locked and stored in the garage. Auditory devices were observed to be in place to monitor exits, if exiting presents a hazard to any resident. Outdoor activity space is completely enclosed by a fence with self-closing latches and gates or walls. No swimming pools or other bodies of water were observed in or around the facility grounds. Facility has posted: Emergency exiting plans and telephone numbers; Facility Theft and Loss Program, Licensing Complaint Poster (PUB 425); Residential Personal Rights; Resident Council Rights, Long Term Ombudsman Contact Information were all observed to be posted. Owner Euphrosyne Diamaano stated to LPAs that they have a Hospice Wavier Request pending for 6.

The Component III Orientation and the Inspection Tool was conducted during today’s Pre-licensing visit. All required documents for licensing were discussed. Pre-licensing passed the Pre-Licensing Inspection/ Comp III Orientation.

Exit interview conducted and a copy of this report was provided to Administrator Peter Nora.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

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