<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606656
Report Date: 05/09/2022
Date Signed: 05/09/2022 02:00:15 PM

Document Has Been Signed on 05/09/2022 02:00 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:KATIE'S HOUSEFACILITY NUMBER:
197606656
ADMINISTRATOR:CARRIE DOBRENENFACILITY TYPE:
740
ADDRESS:15459 GARO STREETTELEPHONE:
(626) 336-8273
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 3DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Nicholas Baez (House Manager)TIME COMPLETED:
02:00 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
Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Nicholas Baez (House Manager) and explained the purpose of the visit.

THE FACILITY IS LICENSED TO SERVE ADULTS AGE 60 AND ABOVE. FIRE CLEARED FOR FOUR AMBULATORY AND TWO NON-AMBULATORY. ROOMS #2 & 3 ARE AMBULATORY ONLY. ROOM #1 IS NON-AMBULATORY.

A tour of the single story facility contains: Living room, kitchen/dining room, 4 resident bedrooms, 2 bathrooms and an attached garage/laundry area.

During today’s visit, LPA observed the following: Sufficient lighting, non-skid mats in all bathrooms, hot water temperature measured between 105 degree F to 120 degree F in the bathroom, all bathing facilities in operable condition containing grab bars, no bodies of water on the premises, no firearms on the premises, toxins stored inaccessible to residents. Smoke detector and carbon monoxide detector are operable. All outdoor passage ways are free of obstruction. Facility maintains a comfortable temperature for the residents. Facility has an approved fire clearance for non-ambulatory persons. There is sufficient staff, the administrator is on the premises during normal business hours. Staff has criminal record clearance, staff have sufficient hours of training and current first aid/CPR training. Facility has sufficient space to accommodate indoor and outdoor activities, furnished areas is provided for relaxation of residents. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature, toxins are stored separate from foods, kitchen is kept clean. All centrally stored medications is labeled and maintained in compliance with state and federal law.

No deficiencies were observed during today's visit.


An exit interview was conducted and a copy of this report was provided to Nicholas Baez.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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 1