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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005542
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:35:31 AM

Document Has Been Signed on 12/14/2023 11:35 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: 6DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Estrelita Fernando, Maxine KniazeffTIME COMPLETED:
11:50 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Estrelita Fernando and discussed the purpose of the inspection. Administrator (AD) Maxine Kniazeff arrived during the inspection.

LPA reviewed Infection Control requirements. At about 8:45AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 6-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 3 staff and 3 clients present at the facility. Client Bedrooms: the 6 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 114 degrees F in the front common client bathroom and 112 in the second bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage and kitchen. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:45AM, LPA reviewed 6 client files and 6 staff files, interviewed 3 clients and 3 staff, inspected medications for 6 clients, and inspected client money and ledgers for 6 clients.

There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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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