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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603678
Report Date: 11/08/2024
Date Signed: 11/08/2024 01:36:58 PM

Document Has Been Signed on 11/08/2024 01:36 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/
DIRECTOR:
GONZALEZ, MARIA LFACILITY TYPE:
740
ADDRESS:5249 BATAVIA RDTELEPHONE:
(562) 889-7345
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 7CENSUS: 0DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Maria Gonzalez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced at 12:30pm, there was no one present upon arrival, shortly after Maria Gonzalez arrived to assist with the visit and LPA explained the purpose for today’s visit. The facility is licensed to serve (6) Bedridden Residents (in rooms 2,3,4) and (1) Ambulatory Resident Ages 59 and over. There is an approved Hospice waiver for (6). The facility currently has (0) Residents.

The facility is a single story home located in South Gate, Ca. A tour of the facility includes: 4 bedrooms, 2 bathrooms (1 of which is inside room #4), living room, dining room, kitchen, laundry area, den, front yard back yard and detached garage.

LPA utilized the Compliance and Regulatory Enforcement(CARE) tools for the visit & observed the following:


Physical Plant & Environment Safety: LPA toured facility, resident bedrooms have closet/drawer space to accommodate each resident. Passageways are free of obstruction. No bodies of water were observed at the facility. All storage areas for cleaning solutions, toxins, knives, and hazardous items have a designated locked area that is inaccessible (locked kitchen cabinet). Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Facility has alarms on all door that lead to exterior that are operable. Food Service: The kitchen was observed for the ability to prepare and serve food. Operational Requirements & Staffing & Personnel Records-Training: Currently facility does not have liability insurance, Administrator is aware that this is needed prior to admitting their first resident. There are currently no staff due to no residents, however, administrator is aware of the required training and fingerprint clearance that staff must complete prior to working with residents. Administrator Maria Gonzalez has a current administrator certificate expires 9/17/25, verified through CCL website. Resident Rights-Information & Resident Records-Incident Reports: Internet and Telephone are connected and readily available for use. Resident rights/reporting posters are displayed within the facility. There is a designated area where resident files will be maintained within a locked cabinet. Disaster Preparedness: The facility has an Emergency Disaster Plan and Infection control plan.
Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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