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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003944
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:55:37 PM

Document Has Been Signed on 07/07/2023 03:55 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:POPPY STREET HOMEFACILITY NUMBER:
306003944
ADMINISTRATOR:RODRIGO MATEOFACILITY TYPE:
735
ADDRESS:3450 E. POPPY STREETTELEPHONE:
(562) 210-5004
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 4CENSUS: 4DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Rodrigo MateoTIME COMPLETED:
02:15 PM
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On 07/07/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Director Rodrigo Mateo as the purpose of today’s visit was explained. The facility is licensed to serve 3 ambulatory and 1 non-ambulatory developmentally disabled adults ages 18-59. Residents are linked to the Harbor Regional center.

The facility is a single-story structure located in a residential neighborhood and consists of the following: The home consists of 4 Bedrooms, 2 Bathrooms, a linen closet, living room, dining area, kitchen, a stocked pantry, an outdoor shaded activity area, an attached garage that serves as storage unit and houses a washer and dryer as well as a refrigerator for staff to use. There is also a detached shed in the backyard that is used for extra storage.

LPA conducted a records review of 3 staff record, 2 resident records, 2 Medication Administration Records and 2 P&I ledgers, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 04/21/23, 1 fire extinguishers fully charged, carbon monoxide detectors observed, smoke detectors are operational, and a landline was observed.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: POPPY STREET HOME
FACILITY NUMBER: 306003944
VISIT DATE: 07/07/2023
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knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no discrepancies were cited.

Exit interview conducted with Director Rodrigo Mateo, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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