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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603628
Report Date: 02/12/2024
Date Signed: 02/12/2024 03:08:33 PM

Document Has Been Signed on 02/12/2024 03:08 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:SANDRA'S HOUSE LLC 4FACILITY NUMBER:
198603628
ADMINISTRATOR:JUSTICE, ANABELFACILITY TYPE:
735
ADDRESS:11902 209TH STREETTELEPHONE:
(562) 281-9228
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Anabel Justice - AdministratorTIME COMPLETED:
03:23 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Anabel Justice (Administrator) and explained the reason for the visit. The facility is licensed to serve 4 ambulatory clients only in the age range of 18 through 59. The facility is operating within the scope of its license.

LPA and Administrator toured the home and inspected 4 client bedrooms, 2 bathrooms, kitchen, dining area, living room, laundry area, front yard, backyard, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in both bathrooms and measured at 115.6 & 112.2 degrees F which is within the required 105 - 120 degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. There is a cabinet in the hallway with extra clean linen and towels. Smoke detectors were observed throughout the facility and were operable. There is a carbon monoxide in the kitchen and hallways and were operable. There is one fire extinguisher located in the kitchen and hallway which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen. Sharps, cleaning supplies, and First Aid kit are locked in the medication cabinet in the dining area and are inaccessible to clients. The First Aid kit fully stocked with all required items and manual. Medications are centrally stored in a locked cabinet in the dining area. Client and staff filed are kept locked in the medication cabinet in the dining area. All four of the client files and medications were reviewed. Medications are documented properly and given as prescribed. Five staff files were reviewed. LPA interviewed 2 staff and 1 client. The 3 others client were at the Adult Day Program (ADP).

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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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