198603627-2-2-2023-28-AS-ACAN-CNNVRS-20230202154025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603627
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:40:34 PM

Document Has Been Signed on 02/02/2023 03:40 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:	LOVING ARMS RESIDENTIAL CARE FOR SENIOR I		FACILITY NUMBER:	198603627
ADMINISTRATOR:	MACANDILI, EDJESKA		FACILITY TYPE:	740
ADDRESS:	11503 THOMAS PLACE		TELEPHONE:	(562) 864-6308
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 4	DATE:	02/02/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Administrator - Edjeska Macandili		TIME COMPLETED:	03:40 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 conducted a Pre-licensing for Change of Ownership and Facility Name Change visit, which included Component III orientation. LPA Calderon met with Applicant Edjeska Macandili, Licensee/Administrator. There are currently four residents in care. LPA 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 Norwalk, CA and consists of a single story building, two bathrooms, a living room, dining room, kitchen and patio located in the back yard and an attached garage used for storage and overflow of food. Facility fire clearance is approved for five (5) non-ambulatory resident’s and one (1) bedridden resident, capacity of 6, approved. Bedroom #4 approved for bedridden, and bedroom 1,2,3 approved or non-ambulatory. Facility will be serving a capacity of 6, elderly adults and has an approved Dementia care plan. Physical Plant Facility was observed to be clean and in good repair. House temperature was between 68 degrees and 85 degrees Fahrenheit. All window screens were clean and in good repair. There was appropriate lighting in the facility and in each room. Protective devices were observed such as nonskid material in restrooms. Indoor and outdoor passageways and stairways were free of obstructions. Stairways, ramps, porch areas and pass ways areas were free of potential hazard , all accessible to residents and well-lit and equipped. No bodies of water were observed or that would be accessible to residents with physical or mental disabilities. The physical plant is consistent with the submitted facility sketch/floor plan. Food Services Area Kitchen and dining room floors 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. 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: 02/02/2023

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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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: LOVING ARMS RESIDENTIAL CARE FOR SENIOR I	FACILITY NUMBER: 198603627
	VISIT DATE: 02/02/2023

NARRATIVE

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Cleaning supplies are kept in areas separate form food supplies. 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. LPA observed sufficient tableware, tables, dishes, and utensils. Knifes were locked and inaccessible to residents in care. All equipment, fixed or mobile, including the dishes were observed to be clean and in good repair. The facility has at least one dining room or dining area convenient to the kitchen.

Records
There is confidential storage area for personnel records, resident records and administrative files, which will be kept in a locked cabinet in the living room storage.

Medications
There is a locked centralized storage are for resident medications in the living room storage. The first aid kit, was observed by LPA to include sterile dressings, bandages, thermometer, scissors, tweezers and a current first aid manual.

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. LPA observed a bed for each resident equipped with good springs, clean and comfortable mattress, pillow(s) and bedding. Mattresses and pillows are flame retardant. All bedrooms were equipped with a chair, nightstand, lamp and sufficient lighting for each resident. There was sufficient drawer and or closet space for each resident.

Bathrooms
Bathroom floors were observed to be clean, sanitary and odorless. The hot water temperature measured between 105-120 degrees Fahrenheit. There was at least one toilet and sink for each six persons and one bathtub and shower for each ten persons. All bathtubs, showers and toilets had grab bars, and non-skid mats. All bathtubs, showers, toilets, and skinks operate properly.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
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

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: LOVING ARMS RESIDENTIAL CARE FOR SENIOR I	FACILITY NUMBER: 198603627
	VISIT DATE: 02/02/2023

NARRATIVE

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Supplies
LPA observed there to be sufficient supply of hygiene items such as soap, and toilet paper locked in the garage storage cabinet. 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 was cloths, to permit changing weekly or more often as needed, stored 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 with pull handles were present, and carbon monoxide detectors was tested and operate properly. No swimming pools or other bodies of water were observed in or around the facility grounds. Activities supplies were in the living room. Fire place is fenced and inaccessible.

The Component III Orientation was conducted during today’s Pre-licensing visit. All required documents for licensing were discussed. The home meets Title 22 Regulations at this time.

Exit interview conducted and a copy of this report was provided to Staff

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
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

LIC809 (FAS) - (06/04)

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