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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603628
Report Date: 03/20/2025
Date Signed: 03/20/2025 12:01:45 PM

Document Has Been Signed on 03/20/2025 12:01 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SANDRA'S HOUSE LLC 4FACILITY NUMBER:
198603628
ADMINISTRATOR/
DIRECTOR:		JUSTICE, ANABELFACILITY TYPE:
735
ADDRESS:11902 209TH STREETTELEPHONE:
(562) 281-9228
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Gabriela De Luna, Direct Support Personnel ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 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 Analysts (LPAs) Mayra Cota and Blanca Gonzalez, conducted an unannounced required annual visit. LPAs met with Gabriela De Luna, Direct Support Personnel Manager, and explained the reason for the visit. Administrator, Anabel Justice, arrived thereafter and assisted with the visit.

The facility is licensed to serve only 4 ambulatory developmentally disabled adults ages 18 to 59 years old. The facility is operating within the scope of its license. Clients receive services through the Harbor Regional Center. The facility is a single-story home, located in a residential area of Lakewood.

LPAs and Administrator toured the home and inspected the entry hallway, four (4) client bedrooms, two (2) bathrooms, activity room, kitchen, dinette, laundry area, two (2) storage closets, den and office space. The front and backyard and detached garage were also inspected. During today’s visit, LPAs observed the following:

In the home:
  • Furniture throughout facility is in good repair.
  • Walkways were clear of obstructions.
  • 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. There is a closet in the hallway with extra clean bed linen and personal hygiene items for clients.
  • Bathrooms were observed clean. The water temperature was tested in both bathrooms and measured at 107.7-degrees F in bathroom 1- and 108.5-degrees F in bathroom 2 which is within the required 105 - 120 degrees F.

Continues on LIC 809C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANDRA'S HOUSE LLC 4
FACILITY NUMBER: 198603628
VISIT DATE: 03/20/2025
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
  • Kitchen appliances were clean and were operating at the time of the visit.
  • Sharps, cleaning supplies and toxins were observed locked in a cabinet under kitchen sink and are inaccessible to clients.
  • Sufficient supply of 2 day perishable and 7 day non-perishable food was observed and an additional emergency food supply and water was observed in the hallway closet. Food is labeled and kept within expiration limits.
  • Current menu and meal plan is posted on the kitchen refrigerator door.
  • Smoke detectors were observed throughout the facility and were tested and observed to be working properly. A carbon monoxide detector located in the hallway was tested and was also observed to be working properly. There are three (3) fire extinguisher located in the hallway, activity room and kitchen and were observed to be charged.
  • Last fire/safety drill was conducted on 3/2/25.

Outdoor environment:
  • The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area accessible to clients, located in the backyard.
  • Patio furniture was observed to be in good repair and there is enough seating area for clients to use.
  • Garden area is clean and maintained.
  • Detached garage is clean and kept locked.


Medication and record review:
  • Staff and client files were observed locked in cabinet.
  • Medication is centrally stored in a locked cabinet in the dinette and are inaccessible to clients.
  • Two (2) client medications were reviewed along with MAR log.
  • Four (4) client and three (3) staff records were reviewed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there are deficiencies cited during today's visit. Exit interview held with Anabel Justice, Administrator, and a copy of the report was provided today.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2