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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005402
Report Date: 04/13/2023
Date Signed: 04/14/2023 06:58:44 AM

Document Has Been Signed on 04/14/2023 06:58 AM - 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:ENDEAVORS RESIDENTIAL CAREFACILITY NUMBER:
306005402
ADMINISTRATOR:PENALOSA, BRANDONFACILITY TYPE:
735
ADDRESS:9301 BIXBY AVENUETELEPHONE:
(310) 938-0700
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 4CENSUS: 4DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Enrique "Iyke" ManabatTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year inspection. Upon arrival LPA was greeted by facility Staff Earl M. Maglaya and Nilda Bognot and reason for visit was explained. LPA spoke to Administrator Brandon Penalosa via telephone and reason for visit was also explained. There are currently 4 clients residing at the facility. No clients and two staff were present during today's visit. Per staff, all clients are at Day Program. Administrator Enrique "Iyke" Manabat arrived shortly after. One client arrived during visit.

LPA Martinez, along with Staff conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, living room, den, garage and observed the following:

Facility is a single story 4 bedroom, 3 bathroom home with an attached 2 car garage that is used for storage only. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. LPA observed a table and chairs under covered patio for clients and visitors. The swimming pool gate was secured. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were observed to be clean, have a supply of soap and paper towels. Hot water temperature was within regulatory requirements. Linen and hygiene supplies were stocked. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted and were last serviced on 08/25/2022. LPA reviewed Emergency Disaster/Fire drill log and their is no record that drills have been conducted. Stove burners, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. There is a laundry room next to the kitchen, and locked cabinets for storing laundry soap and other chemicals. Medications are centrally stored in a locked kitchen cabinet. Medications reviewed appear to have been dispensed accurately.
(see LIC809C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ENDEAVORS RESIDENTIAL CARE
FACILITY NUMBER: 306005402
VISIT DATE: 04/13/2023
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LPA Martinez observed the Emergency and Disaster and Evacuation plan. Facility has a supply of emergency food, water and PPE which is stored in the garage and readily available for staff and clients.

First-Aid Kit had all the required elements. There is a land line in the facility.

LPA reviewed client files and staff files. LPA interviewed 1 client and 1 staff. LPA observed P & I and cash on hand but there was no ledger. Money count could not be accounted for as logs were not available.

Indoor and outside passageways are free of obstruction.

In order to update CCL file, please provide the following updated documents to CCL by 04/25/2023: 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610D); 4.) Surety Bond; and 5.) Administrator certificate.



Based on observations made during today's visit in the areas reviewed, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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