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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608124
Report Date: 02/21/2025
Date Signed: 02/21/2025 01:52:32 PM

Document Has Been Signed on 02/21/2025 01:52 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
GREATER LA AC/SC, 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: 3DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Victoria Tayag, StaffTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 2/21/25. LPA met with Staff, Victoria Tayag, and explained the reason for the visit. The house manager, Dalisay Lazo, arrived shortly to assist with the visit. The facility is licensed to serve six (6) non-ambulatory developmentally disabled individuals, ages 60 and over. There is an approved hospice waiver for 1 resident. The facility is vendorized by the Harbor Regional Center and there are currently 3 residents residing at the facility.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools.
The facility consists of 4 resident bedrooms, 1 staff office, 2 bathrooms, living room, family room, kitchen, and attached garage. There are no swimming pool or bodies of water on premises. Facility has the infection control plan and staff are continuing to clean and disinfect daily. Knives and cleaning products are locked. Sufficient food supplies of perishable and non-perishable are observed. There are operable smoke detectors and a carbon monoxide detector at the facility. The hot water temperature was measured within the required range of 105-120 degrees F.
Medications are centrally stored and locked inside a cabinet. Staff and Residents files are stored and maintained at the facility. LPA reviewed 3 resident medications and they are being administered as prescribed. LPA reviewed resident and staff files to ensure all required forms are in their files. The staff and resident files contain all the required forms. The administrator's (Maria Santos) certificate expires on 4/27/25. Staff have current CPR and First Aid certificates. Staff are receiving on-going training.
The facility accepts and retains residents with dementia and/or hospice.
Emergency Disaster Plan is easily accessible and disaster drills are conducted monthly.

No deficiencies are issued today. An exit interview was held and a copy of this report was given to staff Lazo.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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