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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003751
Report Date: 11/10/2021
Date Signed: 11/10/2021 03:28:43 PM

Document Has Been Signed on 11/10/2021 03:28 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CRJ HOMEFACILITY NUMBER:
306003751
ADMINISTRATOR:CRISTINA SANTOSFACILITY TYPE:
735
ADDRESS:15044 BARNWALL STREETTELEPHONE:
(714) 521-5956
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 4DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Loida Samonte/Facility Manger TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos, conducted a required annual inspection focused on Infection Control Domain using the Inspection Tool. LPA was greeted by Arturo Dalguntas/DSP. Mr. Dalguntas contacted Loida Samonte/Facility Manger by telephone who joined shortly after. The purpose of the visit was discussed. As a part of the inspection, LPA reviewed client files, Staff files, client medications, and toured the physical plant.

LPA conducted a review of (4) client files and (4) staff files. LPA conducted a review of Medication Administration Record (MAR) and medications. All medications and records are maintained in compliance with label instructions. All records are maintained in order.

The home consists of (3) client bedrooms (2) client bathrooms. There are (2) bedrooms for staff. A living room, kitchen, dining area, laundry room, activity room and patio. A garage is being used for storage for supplies and additional refrigerators. During the inspection LPA observed the following client rooms: mattresses and box springs in working condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. LPA observed fully stocked bedding and towel in closets. All bathroom fixtures are in working condition. LPA observed sufficient bedding, linens, and toiletries are accessible to clients. Water temperature properly measured within Title 22 regulations. LPA observed perishable and non-perishable food supply. LPA tested facility Carbon Monoxide and Smoke Detectors and are working properly. The facility has (2) Fire Extinguisher fully charged. All disinfectants, cleaning solutions and toxins were in locked cabinets. Medications are centrally stored in locked cabinet inaccessible to clients. Facility first aid kit was checked and in compliance. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. The facility has a functional operating landline telephone in kitchen. Required postings observed.

LPA did not observed deficiencies; therefore, no citations are issued. Visit Inspection Tool completed.


Exit interview was conducted, and a Facility Evaluation Report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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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