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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004298
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:24:27 PM

Document Has Been Signed on 08/03/2023 03:24 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:SANDRA'S HOUSEFACILITY NUMBER:
306004298
ADMINISTRATOR:SANDRA BENSONFACILITY TYPE:
735
ADDRESS:2821 E. 57TH ST.TELEPHONE:
(562) 470-6300
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 4CENSUS: 4DATE:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Anabel BerovinosTIME COMPLETED:
02:30 PM
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On 08/03/2023 Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual inspection visit , LPA Villegas met with Administrator Anabel Berovinos and the purpose of visit was explained. The facility is licensed for four (4) residents, three (3) ambulatory and one (1) Non-ambulatory developmentally disabled adults. Residents are linked with Harbor regional center.

The one-story residential home consists of (4) resident bedrooms, (2) resident bathrooms, living room, dining room, kitchen, office area, de-attached garage with washer and dryer/ storage area, front yard, backyard with umbrella with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage. Staff are following modified diet as prescribed by doctors’ orders. As part of the inspection, LPA Villegas reviewed: (1) resident file, (1) resident medication records, and one (1) staff file. The facilities’ last fire drill was conducted on 08/01/2023 and smoke detectors and carbon monoxide detectors were observed and are operable. (2) Fire Extinguishers were checked and found to be fully charged and accessible.

LPA observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA observed bathrooms were found to be within Title 22 regulation.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANDRA'S HOUSE
FACILITY NUMBER: 306004298
VISIT DATE: 08/03/2023
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 All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order.

Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards.

During today's visit no deficiencies were observed.

Exit interview conducted with Administrator Anabel Berovinos and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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