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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603817
Report Date: 02/07/2025
Date Signed: 02/07/2025 10:21:31 AM

Document Has Been Signed on 02/07/2025 10:21 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:OAK RESIDENTIAL HOME CAREFACILITY NUMBER:
198603817
ADMINISTRATOR/
DIRECTOR:		GONZALES, MARIONFACILITY TYPE:
735
ADDRESS:9232 OAK ST.TELEPHONE:
(714) 883-8394
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 0DATE:
02/07/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Marion Gonzales - AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:37 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted an announced pre-licensing visit and met with Licensee Rommel Gonzales and Administrator Marion Gonzales. The purpose for visit its to conduct a Pre-Licensing Inspection / Component III visit.

The facility has an approved fire clearance to be licensed to serve a capacity of six (4) ambulatory only clients ages 18-59 years.

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, 4 bedrooms, 3 bathrooms (1 bath is designated for staff in the back staff area), staff meeting room/break area is has its own entrance through the back yard and is separate from clients main living area, there is a front yard, back yard and detached garage with laundry area.

The physical plant was toured inside and out alongside Administrator and Licensee.



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.

· 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.

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

(Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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: OAK RESIDENTIAL HOME CARE
FACILITY NUMBER: 198603817
VISIT DATE: 02/07/2025
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· 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 will be available for clients.

· Client 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 garage.

· 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 Administrator.

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.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
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