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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603647
Report Date: 08/11/2023
Date Signed: 08/14/2023 07:14:44 AM

Document Has Been Signed on 08/14/2023 07:14 AM - 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:KONICE CARE INCFACILITY NUMBER:
198603647
ADMINISTRATOR:EKAUN, WILSONFACILITY TYPE:
735
ADDRESS:14511 NEARGROVE ROADTELEPHONE:
(562) 273-0434
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 0DATE:
08/11/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Applicant John WilsonTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an announced visit with applicant(s) John Wilson, Chinenye Udoh and Ifunanya Ifeacho . The purpose of the visit was to conduct the Pre-Licensing for the facility listed above.

An application was submitted to CCLD on 12/30/2022, for an Initial License of an Adult Residential Facility. Application requested a capacity of 4 residents and has an approved fire clearance for up to (4) Ambulatory residents.

Structure/Physical Plant:
The facility is part of a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, sink/faucet, locked storage cabinet for cleaning supplies, (4) resident rooms, (2) bathrooms for residents of which (1) is a private bathroom attached to room #4; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to residents for storage, and washer and dryer. The residence is equipped with central air and heating.

Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: Bedrooms #1-#4 are for ambulatory residents. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space, and beds for each resident. Bathrooms: Bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is (1) cordless phone for residents use. Fire Extinguisher fully charged and up to date...

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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: KONICE CARE INC
FACILITY NUMBER: 198603647
VISIT DATE: 08/11/2023
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Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates are stored at the other location until residents move in. Knives, cutlery and other sharps inaccessible to residents will be kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working. Smoke detectors and carbon monoxide detectors observed, all detectors tested and operational. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 110 -120 degrees all around the home. Medications, First-Aid Kit & Book: Locked medication cabinet observed. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, which is available for staff use. First Aid Manual observed. Residents & Staff Files: Facility has a locked cabinet location for resident and staff files. Example files observed. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 6/13/23.

Physical Plant cleared at the time of this visit.

Component III:

Component III was conducted at the time of this visit.

An exit interview was conducted and a copy of this report has been furnished to the applicants. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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