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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603665
Report Date: 05/04/2023
Date Signed: 05/05/2023 08:57:49 AM

Document Has Been Signed on 05/05/2023 08:57 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:PRISTINE CARE 1FACILITY NUMBER:
198603665
ADMINISTRATOR:VANKINA, VENKATESWARAFACILITY TYPE:
735
ADDRESS:14639 DALMATIAN AVETELEPHONE:
(720) 272-7437
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 0DATE:
05/04/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Applicant VANKINA VENKATESWARATIME COMPLETED:
10:30 AM
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) Jose Villalobos conducted an announced visit with applicant VENKATESWARA VANKINA. The purpose of the visit was to conduct the Pre-Licensing visit.

An application was submitted to CCLD on 1/24/2023, for a Initial License of an Adult Residential Facility. The requested capacity of 6 residents, (4) ambulatory, (0) non-ambulatory and (0) may be bedridden.

Structure/Physical Plant:
The facility is part of a single story home located in a residential area and contains the following: living room, dining area, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) client rooms, (2) bathrooms for client use; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for client use. A detached garage inaccessible to residents for storage. Washer and dryer on property. The residence is equipped with central air and heating. Facility has a covered fireplace inaccessible to clients.

Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Client Rooms: Bedrooms #1-#4 are for one (1) client each. Bedroom #2 and #3 have a shared bathroom. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: Bathroom #1 and #2 have a working toilet, wash basin, shower 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: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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: PRISTINE CARE 1
FACILITY NUMBER: 198603665
VISIT DATE: 05/04/2023
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
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 clients will be kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working. Smoke detectors and also 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 105 -115 degrees all around the home. Medications, First-Aid Kit & Book: Medications central storage location inaccessible to clients was observed. First aid kit inspected and all required items observed. Residents & Staff Files: Facility has a locked cabinet for client and staff files. Sample files were 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 3/16/23.

The Physical Plant is cleared

Component III:
Component III was conducted with applicant at the time of this visit.

An exit interview was conducted and a copy of this report has been furnished to the applicant VENKATESWARA VANKINA. 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: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2