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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608124
Report Date: 04/19/2024
Date Signed: 04/19/2024 04:41:09 PM

Document Has Been Signed on 04/19/2024 04:41 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:NARRA TREE, INC. - JEFFREY HOMEFACILITY NUMBER:
197608124
ADMINISTRATOR/
DIRECTOR:		MARIA TERESA SANTOSFACILITY TYPE:
740
ADDRESS:18414 JEFFREY AVENUETELEPHONE:
(562) 865-4394
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Maria Teresa SantosTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Maria Teresa Santos and explained the purpose for todays visit. The facility phone number is 562 865 4394..

The facility consist of 4 bedrooms, 2 bathrooms, 1 living room, 1 family room, dining room, office area, kitchen, back yard with shaded area, and attached garage.

LPA Wesley conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the Hallway. The water temperature was tested and measured 105.3 degrees F. The last fire drill was conducted on 04/02/24. LPA Wesley received a copy of the facility infection control plan and insurance at the time of visit.

Administrators certificate for Maria Teresa Santos #6025870740 for expires on 04/27/2025.

There is one deficiency cited according to the California Code of Regulations, Title 22, Division 6, appeal rights given.

A copy of the LIC 809/LIC 809D was given during the exit interview.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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Document Has Been Signed on 04/19/2024 04:41 PM - It Cannot Be Edited


Created By: Nicol Wesley On 04/19/2024 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NARRA TREE, INC. - JEFFREY HOME
FACILITY NUMBER: 197608124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by: LPA observed the blinds in room #2 has blinds that are missing and need replacing.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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The licensee shall replace the blinds in room #2 and send proof of corrections by completing a LIC 9098 Attn Nicol Wesley by POC date 05/03/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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