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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005542
Report Date: 12/20/2021
Date Signed: 12/20/2021 12:48:04 PM

Document Has Been Signed on 12/20/2021 12:48 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:ELIZABETH HOMES - BERRY AVEFACILITY NUMBER:
306005542
ADMINISTRATOR:SANTOS, ELIZABETHFACILITY TYPE:
735
ADDRESS:6892 BERRY AVETELEPHONE:
(714) 995-3988
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maxine Kniazeff, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Kathrina Chin conducted an unannounced visit for the purpose of conducting a required annual visit. LPA were greeted by Estrelita Fernando, Caregiver/Program Support, Erlina Enriquez, Caregiver and Liza Rebecca, Caregiver. LPA met with Maxine Kniazeff, Administrator and explained the purpose of the visit.

LPA toured the facility. There are six residents residing in the facility and no active COVID-19 cases. All residents appeared clean and well taken care of. LPA observed required postings in the facility as well as hand washing signs in the restrooms. All bathrooms observed had ample soap/sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. LPA reviewed the COVID-19 mitigation plan of the facility.

Smoke detectors and carbon monoxide were tested and were operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 110.1 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair and a covered patio, and grounds were free of tripping hazards.


No deficiencies cited this review as per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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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