198603730-9-10-2024-28-AS-THEA-D8YPRG-20240910113243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603730
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:32:48 AM

Document Has Been Signed on 09/10/2024 11:32 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 BLANCA SENIOR CARE LLC		FACILITY NUMBER:	198603730
ADMINISTRATOR:	SANCHEZ, KARINA		FACILITY TYPE:	740
ADDRESS:	13833 BIRKHALL AVENUE		TELEPHONE:	(562) 363-3017
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	6	CENSUS: 0	DATE:	09/10/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Licensee Miriam Galicia		TIME COMPLETED:	11:45 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) Tena Herrera conducted an announced pre-licensed visit and met with Licensee Miriam Galicia and Administrators Karina Sanchez, Andrea Duarte, and Daniela Duarte for the purpose of conducting a Pre-Licensing Inspection / Component III visit.

The facility has an approved fire clearance to be licensed to serve a capacity of six (6) non-ambulatory residents ages 60 and over, of which one (1) may be bedridden in room #1 (room closest to dining area). There is a Hospice Waiver Granted for two (two).

This is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, 3 bedrooms, 1 1/2 bathrooms (1/2 bath is designated for staff), laundry area is in the outdoor patio, there is a front yard and back yard. There is a separate detached ADU in the back of the facility that is currently occupied by licensee, this ADU is not part of the licensed facility, LPA will inform CAB specialist of ADU and CAB will reach out to Licensee for any additional information that may be needed, as ADU was not listed on Facility Sketch not Fire Clearance. ADU has same address as facility.

The physical plant was toured inside and out alongside Administrators.

The following was observed/inspected:

· There is a locked storage area that is centrally located for medication located in the dining area.

· Cleaning supplies are kept separate from food and located in a locked cabinet in the patio.

· Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.

· Fire extinguisher and smoke detectors operate properly.

· Doors and passageways are free of obstruction.

(Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 BLANCA SENIOR CARE LLC	FACILITY NUMBER: 198603730
	VISIT DATE: 09/10/2024

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
26
27
28
29
30
31
32

· There are no pools/bodies of water at the facility and facility does not have firearms on premises.

· There is an emergency exiting plan with emergency phone numbers posted.

· There is a current disaster and mass casualty plan maintained at the facility.

· There is a plan for staffing arrangements and a designated cabinet where personnel files will be stored.

· Operating telephone and desktop computer on the premises and will be available to residents.

· Residents Records have a designated area within a locked cabinet for safe keeping.

· There is a linen closet with extra linens and towels.

· Facility has a laundry area in the patio area.

· First-aid supplies are maintained and readily available.

· Refrigerator and freezer were observed and are maintained at the correct temperatures.

· Food storage and preparation are clean and appropriate for food preparation.

· Hot water temperature was tested and is within the required range of 105-120 degrees F.

Component III was completed during todays visit and reviewed by Licensee and Administrators.

An exit interview was conducted, and a copy of this report has been furnished to Licensee . 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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2