198603629-2-24-2023-28-AS-ACAN-CPCRNU-20230224121055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603629
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:11:05 PM

Document Has Been Signed on 02/24/2023 12:11 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:	CITADEL HOMES 2 LLC		FACILITY NUMBER:	198603629
ADMINISTRATOR:	BUNDALIAN, CHRISTOPHER		FACILITY TYPE:	735
ADDRESS:	12231 183RD ST		TELEPHONE:	(562) 397-3192
CITY:	ARTESIA	STATE: CA	ZIP CODE:	90701
CAPACITY: 4		CENSUS: 0	DATE:	02/24/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Applicant- Christopher Bundalian		TIME COMPLETED:	12:30 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 and Component III orientation visit. LPA Calderon met with Applicant / Administrator Christopher Bundallian and Marissa Mashburn. Application was submitted for an initial license of Adult Residential Facility for ages 18-59. Fire clearance states approved for a total capacity of: four (4), (2) Ambulatory , (1) Non-Ambulatory , and one (1) bedridden. Bedridden approved for Bedroom #1 can also be used for for a non-ambulatory resident. Facility approved Dementia care plan. Applicant stated Hospice Wavier was submitted to CAB for approval, pending confirmation, LPA will reach out to CAB Analyst. LPA alongside with Christopher Bundallian and Marissa Mashburn. Physical plant tour 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 Atresia, CA and consists of a single story building, 4 bedrooms (1 staff room), 3 bathrooms, a living room, dining room/ kitchen, back yard and an attached garage. 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. Indoor and outdoor passageways free of obstructions. Ramps, pass ways and porch areas are well-lit and were free of potential hazard. 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 can had tight fitting covers. Continuation on 9099C...

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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: CITADEL HOMES 2 LLC	FACILITY NUMBER: 198603629
	VISIT DATE: 02/24/2023

NARRATIVE

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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. Additional freezer kept in the garage. LPA observed sufficient tableware, tables, dishes, and utensils. Knifes/sharps were locked and inaccessible located under kitchen sink. All equipment were observed to be clean and in good repair / operable. Facility has at least one dining area convenient to the kitchen.

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

Medications
There is a locked centralized storage area for medications in the dining area closet. The first aid kit / manual was observed by LPA to include sterile dressings, bandages, thermometer, scissors, and tweezers. Emergency supplies/bags/kits were observed.

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. 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.

Bathrooms
Bathroom floors were observed to be clean, sanitary and odorless. The hot water temperature measured between 105-120 degrees Fahrenheit. All bathtubs, showers and toilets had grab bars, and non-skid mats. All bathtubs/showers, toilets, and skinks operate properly.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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: CITADEL HOMES 2 LLC	FACILITY NUMBER: 198603629
	VISIT DATE: 02/24/2023

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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. Cleaning supplies are kept in a locked cabinet in the garage. PPE was observed for approximately 60 days plus.

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 (562-202-9467). Emergency lighting supplies e.g., flashlights, batteries were observed. Fire alarms with pull handles were present, smoke detector 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 kept in the hallway closet accessible to residents in care. Facility will handle client P&I monies and facility will be associated with Harbor Regional Center. Two Transportation Vehicles were observed. Administrator Certificate Expires 8/3/2024.

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

Exit interview conducted and a copy of this report was provided to Christopher Bundallian and Marissa Mashburn.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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