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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002492
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:05:34 AM

Document Has Been Signed on 05/24/2022 11:05 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- LOS MOLINOSFACILITY NUMBER:
306002492
ADMINISTRATOR:ELIZABETH SANTOSFACILITY TYPE:
735
ADDRESS:5940 LOS MOLINOS DRIVETELEPHONE:
(714) 995-1106
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Orencio Esperanza, Antonio Escultor, Medrado Cruz Maxine KniazeffTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at the facility. LPA met with staff Orencio Esperanza, Antonio Escultor, Medardo Cruz and stated the purpose of this visit. Assistant Administrator Maxine Kniazeff arrived at approximately 9:30 AM and provided assistance.

The facility is a single level structure and licensed for six ambulatory with development disabilities. This facility offers a Level IV-I service.

About 9:00 AM, LPA Tapia was granted entry and was not asked to complete the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed three clients in care and three staff members on duty. LPA toured the interior and exterior portions of the facility. There were six private client rooms. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide alarms were tested to be operational. LPA did recommend exit alarms to be purchased for residents with elopement behaviors. Assistant Administrator agreed. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 112.2 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 112.2 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. A two car garage was attached to facility and obtained a operational washer and dryer and was also used a storage unit and pantry. Kitchen was in good repair with knifes and toxins kept locked. Medications and first aid kit was also kept locked.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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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- LOS MOLINOS
FACILITY NUMBER: 306002492
VISIT DATE: 05/24/2022
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LPA did notice a sharp not locked, staff immediately removed sharp and locked, making it inaccessible to clients. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. Three advisories were issued today.

LPA Tapia conducted an exit interview with Assistant Administrator Maxine Kniazeff and copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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