198603676-10-12-2023-28-AS-JBAE-CWJP28-20231012105532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603676
Report Date: 10/12/2023
Date Signed: 10/12/2023 10:55:40 AM

Document Has Been Signed on 10/12/2023 10:55 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:	FELSON BOARD AND CARE		FACILITY NUMBER:	198603676
ADMINISTRATOR:	TANGONAN, MARIA ISABEL		FACILITY TYPE:	740
ADDRESS:	13639 FELSON STREET		TELEPHONE:	(562) 307-7668
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	6	CENSUS: 0	DATE:	10/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:13 AM
MET WITH:	Licensee Maria Tangonan		TIME COMPLETED:	11:10 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	On 10/12/2023 at 8:13 a.m., Licensing Program Analyst (LPA), Jewel Baptiste, conducted an announced visit to the facility for purpose of a pre-licensing inspection. Upon arrival LPA met with the Licensee Maria and Lawrence Tangonan. An application was submitted to CCLD on 08/11/2023, for Initial license for Residential Care facility for the elderly (RCFE) age range 60 and older. The requested capacity is for 6 residents. Approved hospice waiver for 6. Structure: The facility is a single-story house and located in a residential neighborhood area. Facility is 4 resident bedrooms,1 live in staff bedroom, 2 bathrooms, kitchen, living room, dining area and an attached garage. The resident bedrooms are spacious and will easily accommodate the client's furnishings. There is a huge back yard with a covered and shaded area for table and chairs. The passageways, walkways, and driveway are free from obstructions. The front, back and side areas of free of hazards and maintained in a good condition. Signal system: Each resident has a pendant to call for assistance. The facility has a delayed egress on the front and back doors and LPA observed that it was operational. Bedrooms Residents: There is two (2) share bedrooms and one (2) private be in each resident. Bedrooms # 1 through 4 is for non-ambulatory residents. Bedroom #4 can also have 1 bedridden resident. Each bedroom has one or two beds (if shared), one chairs, one night stand, one dresser, one closet and lighting. Report continued on 809c

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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: FELSON BOARD AND CARE	FACILITY NUMBER: 198603676
	VISIT DATE: 10/12/2023

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, skid mats, shower chairs, grab bars and showers.

Medications, First-Aid Kit & Book:

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 and locked in a kitchen cabinet, available for staff use but inaccessible to residents. Resident medications are centrally stored and locked in the kitchen cabinet.

Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in client's closet and the personal hygiene supplies will be stored and locked in the garage or bathroom sink.

Emergency Phone Numbers, Exit Plan & Menu:
The facility has a landline phone # and the phone number is (562) 219-7476. Fire Extinguishers located in the kitchen, hallway, and the garage.

Food Service:
Dishes, cups, and flat ware are stored in the kitchen cabinets, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored and locked in a kitchen cabinet. Food supply adequate stored in the kitchen and consists of the following: 2 days perishable and 7 days non-perishable.

Smoke Detectors
The smoke detectors/ carbon monoxide is electrical & inter-connected. They located in each bedroom and common area, tested and operational.

Appliances:
Stove burners, oven, microwave, washer, and dryer working properly. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The client's bedroom is equipped with central air and heat.
Report continued on 809c

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: FELSON BOARD AND CARE	FACILITY NUMBER: 198603676
	VISIT DATE: 10/12/2023

NARRATIVE

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Toxins:
All cleaning supplies and toxins are locked and stored under the sink or garage.

Water Temperature:
The hot water temperature in bathroom #1, #2 and kitchen and was tested at 110.4 and 112.6-degrees F.

Clients & Staff Files:
Applicant will be handling not handle cash resources for residents. Applicants intend to admit private pay residents and apply for the assisted waiver living program. The records of staff and residents shall be stored in a locked file cabinet in the kitchen. The client and staff files are stored and locked in the file cabinet in the kitchen.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, puzzles, Art supplies, bingo and other recreational materials for resident's use located in the living room.

Fire clearance:
Fire Clearance with bedroom#1 through #4 are okay for non-ambulatory and Bedroom #4 can also have 1 bedridden resident. Fire clearance granted and they were all approved on 6/05/23.

Component III:
It was Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted, and a copy of this report has been granted to the applicant. 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.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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