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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001215
Report Date: 09/28/2021
Date Signed: 09/29/2021 08:50:49 AM

Document Has Been Signed on 09/29/2021 08:50 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ELIZABETH HOMES/SAN RICARDOFACILITY NUMBER:
306001215
ADMINISTRATOR:SANTOS, ELIZABETHFACILITY TYPE:
735
ADDRESS:6303 SAN RICARDO WAYTELEPHONE:
(714) 995-1106
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 5DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Nenit Lopez, Manager & Maxine Kniazeff, AD TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kathrina Chin conducted an unannounced required annual inspection in this facility. LPA met with Maxine Kniazeff, Administrator and Nenit Lopez, House Manager. LPA Chin stated the purpose of this visit.

The facility is a single structure and licensed for six ambulatory.

LPA Chin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. Facility had five residents in care and three staff members on the floor. LPA toured the interior and exterior portions of the facility. There were six private rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 114 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair, and grounds were free of tripping hazards. Side exit door was self-closing and self-latching. There is a sufficient supply emergency food supplies. There are two first aid kits.

LPA Chin reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Chin conducted an exit interview with Maxine Kniazeff, AD; and copy of this report was left in the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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