198603827-5-6-2025-28-AS-DKOI-DGENPJ-20250506103825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603827
Report Date: 05/06/2025
Date Signed: 05/06/2025 10:38:40 AM

Document Has Been Signed on 05/06/2025 10:38 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:	BERTHA HOME CARE		FACILITY NUMBER:	198603827
ADMINISTRATOR/ DIRECTOR:	ANSELMO, YETZIRA		FACILITY TYPE:	735
ADDRESS:	11870 BERTHA ST		TELEPHONE:	(562) 215-3265
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY: 4		CENSUS: 0	DATE:	05/06/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:03 AM
MET WITH:	Licensee/Administrator, Yetzira Anselmo		TIME VISIT/ INSPECTION COMPLETED:	10:50 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 Analysts (LPA) Daniel Konishi made an announced visit and met with Licensee/Administrator Yetzira Anselmo to conduct an announced Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of an Adult Residential Facility (ARF) to serve adults between the ages of 18 - 59. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of an Adult Residential Facility (ARF) to serve adults between the ages of 18 - 59. Per approved Fire Clearance dated 03/04/2025, the facility is approved for four (4) clients that are one (1) ambulatory, two (2) non-ambulatory, and one (1) bedridden. Bedroom #2 strictly for bedridden. Bedroom #1, 3, and 4 approved for non-ambulatory. No flammable liquids permitted to be stored in garage. Garage not permitted to be used as office space or habitable space. Facility must keep records for emergency exit lighting per California Fire Code Section 1032.10.1 Activation test. Emergency lighting equipment shall be tested monthly for a duration of not less than 30 seconds. The test shall be performed manually or by an automated self-testing and self-diagnostic routine. CFC Section 1032.10.2 Power test. Battery-powered emergency lighting equipment shall be tested annually by operating the equipment on battery power for not less than 90 minutes. The requested capacity is for four (4) clients. Structure: Facility is a single-story home located in a residential area consisting of four (4) client bedrooms private bedrooms, two (2) bathrooms, kitchen/dining room, living room, laundry area is located in the garage area of the facility and is inaccessible to clients. Backyard has a covered shaded area. Front yard is fenced and landscaped with grass and back yard is landscaped with cement and gravel. Bedroom Clients: Each four (4) private bedrooms.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: BERTHA HOME CARE	FACILITY NUMBER: 198603827
	VISIT DATE: 05/06/2025

NARRATIVE

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Bedrooms are equipped with one bed, nightstand, lamp, and overhead lighting, chairs for each of the clients, dresser, and closet. Bathrooms: Two (2) full bathrooms equipped with working toilets, wash basins, walk-in shower. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in a locked bathroom cabinet. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Two (2) fully charged fire extinguishers were observed. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible in the kitchen dresser. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Emergency food and water supply was observed. Smoke Detectors: There are electrical smoke detectors located in all bedrooms, common areas, and hallways, and are interconnected. Carbon Monoxide detectors were tested and working properly. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in working condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked and inaccessible to clients underneath the kitchen sink. Fireplace is closed and inaccessible to clients. Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit and not more than 120 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Resident & Staff Files: Designated area for files will be in locked closet. Pools/Jacuzzi/Body of Water: No bodies of water were observed. Fire Clearance: Fire clearance was approved on 03/04/2025 for one (1) ambulatory, two (2) non-ambulatory, and one (1) bedridden.

Component III: Component III was reviewed during inspection. Pre-Licensing is complete, and this facility has no deficiencies. Exit interview was conducted with the Licensee/Administrator, Yetzira Anselmo and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC809 (FAS) - (06/04)

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