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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603678
Report Date: 08/28/2023
Date Signed: 08/28/2023 11:22:21 AM

Document Has Been Signed on 08/28/2023 11:22 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
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:
08/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Maria L. Gonzalez - Administrator/ApplicantTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent pre-licensing inspection and met with Applicant/Administrator Maria L. Gonzalez. The facility will be licensed as a Residential Care Facility for the Elderly to serve (1) ambulatory and (6) bedridden residents within the age of 60 years old and above. There are currently 0 residents in care.

During today's visit, LPA performed a final walk through and toured the facility with the Applicant.
LPA observed the following items that have been corrected:
  • Need a safe container to dispose syringes and needles. - Applicant purchased a sharps disposal container.
  • Auditory device installed in the large door in the family room has been fixed and is now operational. - 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. - The fireplace in the living room is now adequately screened.
  • Backyard did not have proper furnishings and there is no covered area for outdoor use of the residents. - Backyard has shaded area now with adequate outdoor furnishings provided for residents and visitors.
  • Lock the chemicals and other hazardous materials stored in the detached garage in a separate cabinet away from the food items. - Chemicals and other hazardous materials are now stored in a locked cabinet in the detached garage away from the food items.
  • Applicant does not have an existing and valid liability insurance. Applicant agreed to purchase liability insurance. - Applicant has a valid liability insurance effective 8/23/2023 to 08/23/2024 in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate.
  • LPA did not observe the following policies posted in the home: Visitation policy and Labor information. - The visitation policy and labor information are now posted on the wall by the entrance area.

During the pre-licensing inspection, LPAs did not observe items which do not comply with applicable laws and regulations.

The Pre-licensing deficiencies have been resolved. Pre-licensing is now complete.

An exit interview was conducted, and a copy of this report has been provided to Maria L. Gonzalez, Applicant/Administrator. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the Applicant/Administrator has questions regarding the status of the application, they have been instructed to communicate with their assigned CAB Analyst.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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