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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005338
Report Date: 10/13/2021
Date Signed: 10/13/2021 05:06:45 PM

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 AVEFACILITY NUMBER:
306005338
ADMINISTRATOR:SUSIEROSE ABELLAFACILITY TYPE:
735
ADDRESS:6052 WESTERN AVETELEPHONE:
(310) 809-3427
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 6DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Susierose Abella TIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA informed Staff 1 (S1) of the purpose of the visit and was granted entry into the building. LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen.

LPA discussed and observed the following:

There were 6 clients present at the facility and clients were engaged in activities. Client rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed hallways and walkways that were free of obstruction. LPA observed PPE in staff office. LPA discussed updated Covid-19 requirements with administrator, Susierose Abella (AD), and provided technical assistance regarding Covid-19 signage. LPA reviewed Covid-19 procedures, mitigation plan, and sign in sheets used to log temperature. LPA discussed PIN 21-40 ASC: Updated Statewide Visitation, Waiver, and Testing and Vaccination Verification Guidance for Visitors Related to Coronavirus Disease 2019 (Covid-19). LPA discussed COVID-19 surveillance testing,clearance testing, quarantine, emergency plan, staffing, and PPE.

No deficiencies were noted during the visit.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Norman WoodridgeTELEPHONE: (714) 703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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