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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003894
Report Date: 02/23/2023
Date Signed: 02/23/2023 02:02:33 PM

Document Has Been Signed on 02/23/2023 02:02 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SANTOS HOME-CHADWELLFACILITY NUMBER:
306003894
ADMINISTRATOR:JAY S. SAMILINFACILITY TYPE:
735
ADDRESS:11436 CHADWELL STREETTELEPHONE:
(562) 809-5747
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Reginald Samilin - CaregiverTIME COMPLETED:
02:17 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Reginald Samilin (Caregiver) and explained the reason for the visit. The Administrator Jay Samilin showed up shortly after. The facility is licensed to serve 3 ambulatory and 1 non-ambulatory developmentally disabled clients ages 18-59 years old, restricted health conditions.

A tour of the single-story facility included the living room, dining area, kitchen, 4 client bedrooms, 1 staff room, 1 activity room, 2 bathrooms, attached garage, front yard, and backyard. LPA Mora conducted the tour with Reginald Samilin and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked under the kitchen sink. Chemical and cleaning solutions are kept locked under the kitchen sink. Medications are kept locked in the medication closet in the hallway. The First Aid kit is kept locked in the medication closet and it is fully stocked with all required items including a current manual. Clean towels and extra linen were observed in a hallway closet. Dining and living room have sufficient lighting and sitting area. All bedrooms have all required furniture, lighting, and bedding. Both bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 119.8 degrees F and 116.2 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and is fully charged. Smoke detectors were observed throughout the facility and in each room, and were operable during the visit. A carbon monoxide was observed in the hallway and was operable during the visit. The front yard and backyard are clean. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for all four clients. Medications are documented properly and given as prescribed. LPA reviewed 4 client files and 2 staff files. No issues were observed with the files.
(Continued to LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANTOS HOME-CHADWELL
FACILITY NUMBER: 306003894
VISIT DATE: 02/23/2023
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Facility has 30 days supplies of Personal Protective Equipment. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by 04/24/2023.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided..
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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