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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603678
Report Date: 07/31/2023
Date Signed: 07/31/2023 02:27:10 PM

Document Has Been Signed on 07/31/2023 02:27 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA PAZFACILITY NUMBER:
198603678
ADMINISTRATOR:GONZALEZ, MARIA LFACILITY TYPE:
740
ADDRESS:5249 BATAVIA RDTELEPHONE:
(562) 889-7345
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 7CENSUS: 0DATE:
07/31/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Maria L. Gonzalez - Applicant/Licensee/AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an announced Pre-Licensing facility Evaluation visit. LPA met with Maria Gonzalez, Applicant/Licensee/Administrator who assisted LPA with the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and the following was inspected during the evaluation with Maria Gonzalez. The physical plant was toured inside and out and the following are observed:
Physical Plant & Environment Safety:
  • The facility is in a residential neighborhood in the city of South Gate. This single-story home contains four (4) bedrooms, two (2) full bathrooms, an office area, a living room, family/activity room, kitchen, dining room, backyard, and detached garage. Fire clearance granted for six (6) bedridden and one (1) ambulatory residents
  • Both bathrooms have the required grab bars and non skid mats in the shower room.
  • Sufficient supply of linens available to permit weekly changing and personal hygiene supplies are available.
  • Facility has auditory device installed in every exit doors that will alert staff to monitor exits. However, the auditory device installed on the large French door type in the family room leading to the backyard was not working.
  • Laundry area is located next to the kitchen.
  • The fireplace located in the living room is not adequately screened.
  • Smoke Detectors were observed throughout the home and were tested and operable.
  • Three (3) fire extinguishers are observed mounted on the wall in the living room, kitchen/laundry area and family room. The fire extinguishers were purchased on 5/26/2023.
  • Cleaning solutions and sharps were locked and stored separately from where food supplies are stored.
  • Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher are in working condition, clean and sanitary.
  • There is insufficient PPE supplies. Applicant agreed to stock up on 30-day PPE supplies.
  • Applicant/Licensee did not have a safe container to dispose syringes and needles.
  • Doors, exits, hallways, and passageways were clear and free of obstruction.
  • LPA observed chemicals and other hazardous materials stored in the detached garage were not locked and accessible to residents. Applicant agreed to store them in a separate cabinet away from the food items.
  • No pools or bodies of water were observed in or around the property.
  • There are no firearms present at the property.
  • The home does not have a video camera monitor system inside and outside the property.
  • Hot water temperature readings were as follows: kitchen measured at 105.2 deg F, bathroom #1 at 106.7 deg F and bathroom #2 at 105.8 deg F which is within Title 22 Regulations.

*****CONTINUED LON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CASA PAZ
FACILITY NUMBER: 198603678
VISIT DATE: 07/31/2023
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Operational Requirements:
  • The Infection Control Plan has been submitted to CCL and the CAB Analyst.
  • The facility has a fire clearance granted by the City of Arcadia Fire Department.
  • Fire clearance granted for six (6) bedridden and one (1) ambulatory residents.
  • The applicant does not have a Liability Insurance in place.
  • Applicant stated that she will not handle resident's cash resources.
  • One (1) operating telephone (323-484-9973) was observed and tested by LPA on the premises. Telephone is easily accessible and available for residents' use.

Resident Rights-Information:
  • The home has adequate furnishings and equipment to meet the residents' needs.
  • LPA did not observe the following policies in the home: Visitation policy and Labor information posted in the home.

Food Service:
  • Meals will be stored and prepared in a safe manner, necessary to meet the needs of residents.
  • Toxic substances are stored in a locked cabinet under the kitchen sink.
  • Food storage and preparation areas, which include pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly.
  • The refrigerator was observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit.


Planned Activities:
  • Backyard did not have proper furnishings and there is no covered area for outdoor use of the residents.

Incidental Medical & Dental:
  • First Aid supply was observed and is kept in the medication cabinet in the family room which included all required supplies.
  • Applicant did not have a safe container to dispose syringes and needles in accordance with the Title 22 Regulations 87303 (g)(1).
  • List of emergency contacts such as Police, Fire Dept. or paramedic unit was posted in a visible location.
  • The home has one medical resource available to be called at all times.


Disaster Preparedness:
  • The home has a complete Emergency and Disaster Preparedness Plan that includes, EVAC Procedures, Transportation arrangements, Location of all utility shut-off valves and instructions for use
  • There is a contact information list of local emergency response personnel, clients authorized representative or local emergency contact name posted and visible to staff and residents.

Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility did not meet the physical plant requirements/ inspection as required per California Code of Regulations Title 22 Division 6.


The following corrections need to be made prior to clearing the physical plant:
  • Need a safe container to dispose syringes and needles.
  • Auditory device installed in the large door in the family room is not working and needs to be fixed.
  • The fireplace located in the living room is not adequately screened.
  • Backyard did not have proper furnishings and there is no covered area for outdoor use of the residents.
  • Lock the chemicals and other hazardous materials stored in the detached garage in a separate cabinet away from the food items.
  • Applicant does not have an existing and valid liability insurance. Applicant agreed to purchase liability insurance.
  • LPA did not observe the following policies posted in the home: Visitation policy and Labor information.

LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the pre-licensing facility evaluation visit report, as well as the items needing corrections.

Exit interview conducted and a copy of this report was provided to Maria Gonzalez, Applicant/Licensee/Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC809 (FAS) - (06/04)
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