<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603625
Report Date: 02/13/2024
Date Signed: 02/13/2024 02:57:47 PM


Document Has Been Signed on 02/13/2024 02:57 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 CERRITOSFACILITY NUMBER:
198603625
ADMINISTRATOR:NORA, PETERFACILITY TYPE:
740
ADDRESS:19627 WIERSMA AVETELEPHONE:
(714) 322-6480
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 5DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Peter NoraTIME COMPLETED:
03:12 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
On 2/13/24 at 12:15 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Nora’s Home Care in Cerritos. Upon arrival LPA was greeted by S1 and the administrator’s arrived shortly after. This home is license to serve age range 60 and over. 6 non ambulatory, of which 1 may bedridden. Bedroom #5 approved for bedridden. Hospice wavier approved for 6. All residents were in care during the time of this visit. The last emergency disaster/fire drill was conducted on 01/19/2024. The Administrator Certificate expires on 2/014/2024 #6031894740. The administrator’s certificate is currently on the pending list. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (5) residents files, medications, and medication administration records for (5) residents.

This home contains 5 bedrooms, 2 bathrooms, living room, office/family room, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (5) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and skid mats. The temperature measured at 107.2*F-119.3*F. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (1) fire extinguishers located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked in kitchen draw and cleaning agents/ toxins was locked in garage. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
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)
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: NORA'S RESIDENCE CARE OF CERRITOS
FACILITY NUMBER: 198603625
VISIT DATE: 02/13/2024
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
26
27
28
29
30
31
32
The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The office contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

Exit interview conducted with Peter Nora, Administrator, a copy of this report was provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
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
LIC809 (FAS) - (06/04)
Page: 2 of 2