<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003751
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:27:01 PM

Document Has Been Signed on 11/27/2023 03:27 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:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:House Manager Loida SamonteTIME COMPLETED:
03:40 PM
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 Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with House Manager Loida Samonte and the purpose of the visit was discussed. The following (CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan.
Operational Requirements:
  • A current Plan of Operation was reviewed.
  • A fire clearance for six ambulatory clients of which (0) may be non ambulatory; 0 may be bedridden.
Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential area and contains the following: dining room, living room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for sharps, (4) client rooms, (2) bathrooms with shower, toilet and washbasin, and space for washer and dryer. Backyard also has a shaded area and seating for client use. There is an attached garage kept inaccessible to clients. The residence is equipped with central air and heating.
  • The physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.
  • Fire Alarms were inspected. Fire extinguishers Observed
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.
Staffing
  • Sufficient staff observed to meet clients needs
  • Facility provides care and supervision for a total of (4) Clients.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CRJ HOME
FACILITY NUMBER: 306003751
VISIT DATE: 11/27/2023
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
26
27
28
29
30
31
32
Personnel Records-Training:
  • Administrator on record is current. Administrator Certification is active
  • Staff have criminal background clearance and training.
  • Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR and CPI training was observed.
Client Records-Incident Reports:
  • A total of four (4) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.
  • Complaint poster and Personal rights were observed posted.
Client Rights-Information
  • No postural Supports Observed
  • Internet source provided to clients in care
Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar was reviewed
Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Sanitation practices and kitchen cleanliness was observed.
Incident Medical and Dental:
  • Four Client (4) centrally stored resident medications were reviewed.
Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
Clients with Special Health Needs:
  • There are currently (4) Clients and none are on Hospice or Home Health
  • Individual Service Plans and Appraisals are on file.
  • No residents have prohibited health conditions.


All (12) domains have been completed as of todays visit. Per California Code of Regulations, Title 22, No deficiencies are being cited. Exit Interview Conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2