198603722-3-7-2024-28-AS-SVAD-D35QP7-20240307112016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603722
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:20:27 AM

Document Has Been Signed on 03/07/2024 11:20 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CRISJADE HOME, LLC		FACILITY NUMBER:	198603722
ADMINISTRATOR:	LOSOYA, MARTHA		FACILITY TYPE:	735
ADDRESS:	14736 FIGUERAS RD		TELEPHONE:	(657) 239-0013
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 4		CENSUS: 0	DATE:	03/07/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Martha Losoya- Administrator		TIME COMPLETED:	11:35 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), Sanjay Vaid conducted an announced visit to the facility for purpose of a Pre-licensing evaluation. Also present at today's visit was Martha Losoya, Administrator and Loida Samonte, Licensee. An application was submitted to CCLD on 10/23/2023, for Initial license for an Adult Residential Facility to serve age range 18 through 59. The requested capacity is for 4 non-ambulatory. Structure: The facility is a single story house and located in a residential neighborhood area. Facility is a 4 bedrooms, 2 bathrooms, kitchen, living room, dining area. The client bedrooms are spacious and will easily accommodate the client's furnishings. The yard has a covered, shaded area for table and chairs. The passageways, walkways, driveway are free from obstructions. The front, back and side areas are free of hazards and maintained in a good condition. Bedrooms Residents: There is one bed in each client's bedroom. Each bedroom has one beds, one chairs, one night stand, one dresser, one closet and overhead lighting. Bathrooms: All bathrooms have working toilet, washbasin and shower. 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 file cabinet in the living room. Emergency Phone Numbers, Exit Plan & Menu: The facility has a landline phone # and the phone number is 657-239-0113. Tested & readily available for use. Fire Extinguisher located in the living room and kitchen are both mounted on wall. Sample menu is provided. 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 under the sink. Food supply adequate stored in the kitchen and consists of the following: 2 days perishable and 7 days non-perishable. Continued on LIC 809 C.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CRISJADE HOME, LLC	FACILITY NUMBER: 198603722
	VISIT DATE: 03/07/2024

NARRATIVE

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Smoke Detectors: The smoke detector/carbon monoxide detector(s) were tested & are inter-connected. There is a carbon monoxide detectors located in kitchen area and is operational.
Appliances: Stove burners, oven, microwave, refrigerator, washer, and dryer working properly. The facility is equipped with central air and heat.
Toxins: All cleaning supplies and toxins are locked and stored under the kitchen sink.
Water Temperature: The hot water temperature in bathroom and kitchen was tested and measured between 105 and 120 degree degrees Fahrenheit as required.
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 cabinet, available for staff use but inaccessible to clients. Clients' medication is centrally stored and locked in the cabinet in the living room.
Clients & Staff Files:
Applicant will be handling client cash resources, cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked file cabinet in the living room. The client and staff files are stored and locked in the file cabinet in the living room.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, and they are located in the living room.
The following must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA Vaid by 3/21/2024.
Provide picture of shaded area, with canopy cover. Covering of exposed waterheater located in laundry room.

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 furnished 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.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/25/2024 04:27 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/25/2024 08:33 AM

Created By: Sanjay Vaid On 03/07/2024 at 10:34 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CRISJADE HOME, LLC	FACILITY NUMBER: 198603722
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Fernando Fierros

LICENSING EVALUATOR NAME:

Sanjay Vaid

LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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