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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603030
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:48:05 PM


Document Has Been Signed on 02/24/2022 02:48 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:DIGNITY CARE HOMEFACILITY NUMBER:
198603030
ADMINISTRATOR:LOBARBIO, CHARLENE EFACILITY TYPE:
740
ADDRESS:11643 169TH STTELEPHONE:
(562) 682-4330
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:6CENSUS: 1DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Caregiver's Alberto Lobarbio and Maria LobarbioTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Caregiver Alberto Lobarbio and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Caregiver Maria Lobarbio today 02/24/2022 at 10:00 AM and the following was observed:
Facility contains 3 Bedrooms and 2 Bathrooms, dining room, living room, TV room, and activity room.
Required Annual inspection included Infection Control Domain and check of the food supply, medications and criminal clearance check.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated. Medication for clients were verified as being administered and a 30 day supply on hand.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Temperature checks are conducted.
Staff have been trained in hand washing.
Staff are sufficient with no shortages and there is a plan to replace workers if ill.
There are rooms available if isolation is needed.
Bathrooms have proper signage for hand washing. There are multiple stations for hand sanitizing.
Social distancing is implemented. Meal times are sanitized after each meal.
Facility has sufficient supply of PPE. Facility has a specific plan to ensure proper cleaning and disinfection of environmental surfaces and laundry; commonly touched surfaces are cleaned and disinfected at least once every shift . Plan when to notify medical provider if symptoms develop or COVID-19 exposure or when to call 911 for severe respiratory distress. Advisory notice issued (LIC 9102.) Exit interview conducted.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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