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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001215
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:37:06 PM

Document Has Been Signed on 07/07/2022 02:37 PM - 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: 6DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Maxima Kniazeff & Shirley KniazeffTIME COMPLETED:
01:46 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. LPA Haley was temperature checked before entering the facility. Administrator (AD) Maxima Kniazeff arrived and was present for the visit. AD Kniazeff has a current administrators certificate that expires 7/28/22.

At 1:08 PM LPA Haley began the tour of the facility. A screening station was observed at the entrance of the facility. There was a temperature thermometer for screening clients and visitors, hand sanitizer, and a screening log book. In a closet near the entrance of the facility, there's emergency bags prepared for all clients.

There were six clients present for the visit. All client bedrooms were clean, organized, and had all necessary requirements. Both client bathrooms were clean and organized. Hot water temperature was measured at 111.2 degrees Fahrenheit in client bathroom #1 and 117.2 degrees Fahrenheit in client bathroom #2. LPA Haley observed client files and medication locked and secure in a cabinet near bathroom #2.

There was a first aid kit with all the requirements, and a disaster kit with an additional first aid kit locked in a hallway cabinet. LPA Haley observed plenty of extra linen, hygiene, and grooming items for all the clients in the additional hallway cabinets.

The kitchen was clean and well organized. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. All knives and sharp objects were locked in a drawer. All hazardous chemical are locked under the sink.

In the dining room LPA Haley observed a cabinet with emergency food and water, and additional emergency supplies. The garage is used for a storage and was clean, organized, and walkways were free or tripping hazards. An additional supply of water and cleaning supplies was observed.


Continued on LIC 809C Dated: 7/7/22
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ELIZABETH HOMES/SAN RICARDO
FACILITY NUMBER: 306001215
VISIT DATE: 07/07/2022
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There was an additional food and water supply stored in the garage.The backyard was clean, organized, and free of clutter. Side exit gates are self closing and self latching. There was a shaded area with a table and chairs. No bodies of water were observed.

All smoke detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to the Administrator Maxima Kniazeff.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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