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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005238
Report Date: 10/19/2021
Date Signed: 10/20/2021 07:10:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JUSTIN HOME CAREFACILITY NUMBER:
306005238
ADMINISTRATOR:NOLETTE UNTALANFACILITY TYPE:
735
ADDRESS:5904 EQUADOR WAYTELEPHONE:
(562) 728-7577
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 4DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lorna Cruz, Sheila Managlang, and Joshua EstrevilloTIME COMPLETED:
10:45 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Jerome Haley conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Lorna Cruz and explained the reason for the visit. Licensee Sheila Manalang and Assistant Administrator Joshua Estrevillo arrived during the visit. Licensee Sheila Manalang has a current administrator certificate expiring on 01/17/2022.

At 8:45 AM, LPAs toured the facility with Caregiver Cruz. Assistant Administrator Joshua Estrevillo joined the tour in progress. Facility has two clients present during today's visit, with two clients on home visits. LPAs observed clients relaxing in the facility. LPAs spoke with two clients who appeared happy and well taken care of. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility takes client and staff temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. The facility mitigation plan has been completed and approved. LPAs observed adequate emergency food as well as the first aid kit. First aid kit contained all required items. LPAs observed locked medication drawer. Fire extinguishers are mounted and charged. LPAs toured the outside grounds and observed multiple outside shaded visitation areas. Exit gates are unlocked and self latching. LPAs observed the posted activity schedule including exercise, sports, and gardening. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. All staff and most clients are vaccinated for Covid-19. LPAs reviewed all client files and all contained required documentation including updated emergency information.

LPA consulted with Assistant Administrator on the importance of maintaining an ample supply of emergency water at all times.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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