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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005542
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:45:41 AM

Document Has Been Signed on 11/03/2022 11:45 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: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: 4DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Estrelita FernandoTIME COMPLETED:
11:50 AM
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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 called the Assistant Administrator (AD) Maxine Kniazeff who arrived and was present for the visit. AD Kniazeff has a current administrators certificate that expires 07/28/24.

At 10:16 AM LPA Haley began the tour of the facility with staff. Next to the front door LPA observed a screening station with log sheets, hand sanitizer, surgical mask and temperature thermometer. There were four clients present for the visit. All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. In the hallway near bedrooms 1-3 LPA observed a cabinet full of emergency food supplies, an emergency supply of water, and an emergency supply of PPE. In the cabinet next to the emergency supplies LPA observed an additional supply of non-perishable food items and the top portion of the cabinet is locked and is for client P&I, a first aid kit and an emergency disaster kit.

The living room and the recreation room was clean and well organized. LPA Haley observed a TV, radio, and games for the clients to enjoy in the recreation room. Both client bathrooms were clean and organized. Hot water temperature was measured at 112.8 degrees Fahrenheit in client bathroom #1 and 111.9 degrees Fahrenheit in client bathroom #2.

The kitchen was clean and organized. All knives and sharp objects were locked in a drawer next to the stove. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. A fully charged fire extinguisher is mounted on the wall next to the locked medication cabinet.

The backyard was clean and organized. Both side exit gates were self closing and self latching. LPA observed a large table and bench with plenty of shaded provided by tint like covering. Three locked storage sheds was observed in the backyard.


Continued on LIC809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ELIZABETH HOMES - BERRY AVE
FACILITY NUMBER: 306005542
VISIT DATE: 11/03/2022
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In storage shed #1, LPA observed a Christmas tree and some gardening tools. In storage shed #2, LPA observed several cans of paint. In storage shed #3, LPA observed extra furniture.

The garage was clean, well organized, and remains locked at all times. LPA observed a washer and dryer, a locked cabinet with hygiene supplies, and a locked cabinet with hazardous chemicals. LPA observed emergency bags for all the clients, boxes of adult diapers, two wheelchairs, and extra linen.

No bodies of water observed during the visit. All smoke detectors were tested and are operational.

No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report and LIC9102 was provided to Assistant Administrator Maxine Kniazeff.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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