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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603653
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:39:16 PM

Document Has Been Signed on 06/01/2023 01:39 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:JOYCE CARING HOMEFACILITY NUMBER:
198603653
ADMINISTRATOR:BUMANLAG, MYLENEFACILITY TYPE:
735
ADDRESS:13975 LIGHT ST.TELEPHONE:
(562) 693-4073
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 6CENSUS: 5DATE:
06/01/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mylene Bumanlag and Jennifer KimTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted an announced visit to the facility for the purpose of a Pre-Licensing Inspection. LPA met with Licensee/Administrator, Mylene Bumanlag, and Licensee, Jennifer Kim. Mr. Michael Kim was also present during today's visit.

An application was submitted to Community Care Licensing Department (CCLD) on 1/12/23, for a Change of Ownership for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18-59 years. The requested capacity is for four ambulatory clients and (2) non-ambulatory clients. There are currently 5 clients in care.

Structure: Facility is a four (4) bedroom, three (3) full bathrooms, single story house, with a detached garage. Detached garage has been converted to be used as office space. There is a kitchen, dining area, laundry room, and 2 living room areas. Front and backyard landscape are in good condition and free of obstruction or debris. Rear patio is covered and provides shading. Patio furniture, which consists of a table and (5) chairs. Signal System: No signal system in facility. Bedroom Residents: The three (3) client bedrooms each consists of (2) two twin beds with proper bedding, including mattress pads, a dresser, night stand, proper lighting in addition to a lamp, and a chair. Bedrooms contain ample closet space. Bedroom Staff: There is (1) one staff bedroom to be used by live in staff. Bathrooms: (3) full bathrooms are available for resident use. Water temperature measured 113.8 degrees F in bathroom #1, 116 degrees F in bathroom #2, and 116.2 in bathroom #3. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, a pillowcase, a mattress pad, a fitted sheet, a blanket and a bedspread. Adequate supply of linen is stored in hallway closets. Emergency Phone Numbers, Personal Rights, Visiting Policy, Exit Plan, & Menu: Emergency Disaster Plan, Personal Rights, Visiting policy, emergency numbers, and menu are posted and readily available for review in dining room area. Facility has a land line telephone located in the living room dining area. One (1) fire extinguisher is located in the dining area and is fully charged. Activity Supplies: sufficient activity supplies were observed.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOYCE CARING HOME
FACILITY NUMBER: 198603653
VISIT DATE: 06/01/2023
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 Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked kitchen cabinet drawer. Dishwasher in kitchen is properly installed and functioning. LPA observed a sufficient amount of pershable and non-perishable food supply on today's visit. Smoke Detectors: There are six (7) smoke detectors throughout the facility, and two (2) battery operated carbon monoxide detector located in the hallway. All were tested and appear to be operating properly. Appliances: Stove burners, oven, microwave, and washer/dryer are in working condition. The washer/dryer is located in the laundry area, in the arage. There is one (1) refrigerator in the home. The home is equipped with three (3) wall air conditioning units: one (1) in the living room and the others in bedrooms #1 & 2. There is central heating. Toxins: Cleaning supplies, and toxins are stored in a locked cabinet in the laundry area. Water Temperature: Water was tested in kitchen and 3 bathrooms. Water temperature measured between 112.2 degrees F and 116.2 degrees F in all faucets measured. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in locked kitchen cabinet. A first-aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in locked kitchen cabinet. Client & Staff Files: Designated area for files will be located in locked cabinet in the dining area. Transportation: Facility van was observed and reviewed for safety. Pools/Jacuzzi & Pets: There are no bodies of water or pets on premises. Component III: Conducted at the Pre-Licensing visit. LPA did not observe any corrections needed at the time of the visit.

An exit interview was conducted and a copy of this report has been provided to the applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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