306005542-1-9-2025-22-AS-EKIM-DCS2UQ-20250109164245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005542
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:42:48 PM

Document Has Been Signed on 01/09/2025 04:42 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ELIZABETH HOMES - BERRY AVE		FACILITY NUMBER:	306005542
ADMINISTRATOR/ DIRECTOR:	SANTOS, ELIZABETH		FACILITY TYPE:	735
ADDRESS:	6892 BERRY AVE		TELEPHONE:	(714) 995-3988
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 4	DATE:	01/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Assistant Administrator- Maxine Kniazeff		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On January 9, 2025, at 1:30pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Direct Support Professional (DSP) Zoraida Cadiente. LPA Kim met with Quality Assurance (QA) Shirley Kniazeff and Assistant Administrator Maxine Kniazeff and explained the purpose of the visit.

The facility is licensed to operate for six (6) ambulatory clients. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client bedrooms, two (2) bathrooms, living area, dining area, recreation room, kitchen, activity room, storage room, three storage sheds in the backyard, outdoor covered patio area, and an attached 2-car garage.

LPA Kim toured inside and outside of the physical plant with QA Shirley Kniazeff. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Client’s rooms were inspected: Client Room 1, Client Room 2, Client Room 3, and Client Room 4. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 111.2 degrees F to 111.7 degrees F. A comfortable temperature of 70 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected with a two-day supply of perishable food available and maintained properly. The seven-day supply of non-perishable food is available and maintained properly in the resident hallway cabinet next to Client Bedroom 2. Emergency food, emergency water, and emergency supplies were stored in cabinets next to the non-perishable food cabinet.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELIZABETH HOMES - BERRY AVE	FACILITY NUMBER: 306005542
	VISIT DATE: 01/09/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the visit, LPA Kim observed the facility's infection control practices and plan of operation. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-752-6167) and tablets with internet access for video teleconferencing purpose remain available. The facility has two (2) fire extinguishers that are charged, one mounted in kitchen and one in the garage. The Fire Extinguisher were last serviced on October 2, 2024. Emergency drills are conducted monthly and last conducted on January 5, 2025. Evidence of liability insurance is effective from January 14, 2024, and expires on January 14, 2025.

LPA Kim conducted an audit of four (4) client files (C1-C4), six (6) staff files (S1-S6), P&I Funds, and medication and medication administration review that were all in order and complete. LPA Kim conducted two (2) staff interviews.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to Assistant Administrator Maxine Kniazeff

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2