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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006206
Report Date: 12/05/2022
Date Signed: 12/05/2022 11:10:41 AM

Document Has Been Signed on 12/05/2022 11:10 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 / STANTONFACILITY NUMBER:
306006206
ADMINISTRATOR:KNIAZEFF, MAXINEFACILITY TYPE:
735
ADDRESS:7161 STANTON AVE.TELEPHONE:
(714) 994-1176
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 0DATE:
12/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maxine Kniazeff - Administrator, Licensee- Elizabeth Santos TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Andrea Mendivil made an announced visit to conduct a pre-licensing inspection. LPA identified themselves and discussed the purpose of the visit with Administrator Maxine Kniazeff. Licensee Elizabeth Santos arrived at 9:20 AM. An initial application to operate an Adult Residential Facility was received by CCL on 10/13/2022 for a capacity of six ambulatory clients. Facility has a screening area in the entrance of the facility.
LPA Mendivil along with Licensee and Administrator toured the facility at 9:25AM and observed the following:
Structure: Facility is a single story, 6 bedroom, 2 bathroom and 1 office space house with a terracotta exterior. Facility has an attached secondary office which contains 1 bathroom and access to the garage. The exit gate is unlocked and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Dining room contains a fireplace which has a cover. Bedrooms Residents: All client rooms are single occupancy, All of the rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: Client bathroom has a working toilet/ wash basin. Facility has sanitizer and paper towels in the restrooms .Linens & Hygiene Supplies: Facility has bedding and towels for clients in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Licensee has 2 day perishable and 7-day nonperishable foods. Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested and operational. Fire extinguisher present in kitchen of facility. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: LPA observed a secure area for sharps and toxins. Water Temperature: LPA tested hot water and it read as following: client bathroom read at 113 degrees, bathroom #2 read at 107.4 degrees and kitchen read at 113.5 degrees. Emergency Supplies: LPA observed supply of emergency water and food. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. CONTINUED ON LIC 809C DATED 12/5/2022
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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: ELIZABETH HOMES / STANTON
FACILITY NUMBER: 306006206
VISIT DATE: 12/05/2022
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Medication is stored in a locked staff office. Facility to use a medication administration record. Resident & Staff File: Records are stored in a locked cabinet.. Reading Material, Games, and Equipment: . LPA observed games and books in facility. Backyard: LPA observed a pool space that has been filed with dirt. LPA observed shaded table with 6 chairs for clients. Fire Clearance: Approved for six ambulatory on 08/05/2022.

Component III waived due to Licensee operating other facilities. Facility is ready to be licensed. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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