306005338-7-8-2022-22-AS-JHAY-CG5UD4-20220708152854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005338
Report Date: 07/08/2022
Date Signed: 07/08/2022 03:29:00 PM

Document Has Been Signed on 07/08/2022 03:29 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	STEADFAST WESTERN AVE		FACILITY NUMBER:	306005338
ADMINISTRATOR:	SUSIEROSE ABELLA		FACILITY TYPE:	735
ADDRESS:	6052 WESTERN AVE		TELEPHONE:	(310) 809-3427
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 5	DATE:	07/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Susierose Abella		TIME COMPLETED:	03:35 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff contacted Administrator (AD) Susierose Abella, who arrived and was present for the visit.

LPA Haley was pre screened and temperature checked before entering the facility. A screening station was set up near the front door, and all required postings were observed on the walls throughout the facility. AD Abella has a current administrators certificate that expires 8/18/22.

At 2:15 LPA Haley began the tour of the facility. In the locked office right next to the front door, LPA observed staff files, emergency food, emergency water, two emergency kits, and a first aid kit with all required elements. LPA Haley observed plenty of PPE and cleaning supplies in the closet of the locked office.

All client bedrooms were clean, well organized, and had all the necessary requirements: night stand, chair, lamp and storage space. Client bathrooms were clean and organized. Hot water temperature measured at 106.7 degrees Fahrenheit in bathroom #1 and 105.7 degrees Fahrenheit in bathroom #2. LPA Haley observed a wash room equipped with a washing machine and dryer. All hazardous chemicals and cleaning supplies are stored in the locked cabinets in the wash room.

The back yard was clean and free of clutter. A covered area with a table and chairs was observed. There was a locked storage cabinet that stored cleaning and gardening tools. The garage was well organized, free of clutter and walkways were free of obstruction. In the garage LPA Haley observed extra linens and clothing for the clients. In the garage an additional refrigerator was observed with plenty of fresh food items.

Continued on LIC 809 C Dated 7/8/22

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STEADFAST WESTERN AVE	FACILITY NUMBER: 306005338
	VISIT DATE: 07/08/2022

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The kitchen area is secured by a child safety gate to keep clients out. All knives are kept locked under the sink. All burners on the stove were operational. LPA Haley observed a two day supply of perishable food items and a seven day supply of nonperishable food items. A locked file cabinet with client medication and files, as well as a charged and mounted fire extinguisher was observed.

No bodies of water were observed. Smoke detectors were tested and were operational.

No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to the Administrator Susierose Abella.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

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