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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320105
Report Date: 04/10/2024
Date Signed: 04/10/2024 04:44:35 PM

Document Has Been Signed on 04/10/2024 04:44 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:AVIATION GUEST HOMEFACILITY NUMBER:
198320105
ADMINISTRATOR/
DIRECTOR:
DEMAFELIX, JEHN MARICFACILITY TYPE:
740
ADDRESS:317 S. AVIATION BLVDTELEPHONE:
(310) 533-1131
CITY:MANHATTAN BEACHSTATE: CAZIP CODE:
90266
CAPACITY: 6CENSUS: 5DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Irene FormenteraTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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RCFE Sample Inspection

Licensing Program Analyst (LPA) Troy Watson and Licensing Program Manager (LPM) Janae Hammond conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one year inspection. LPA met with the administrator Irene Formentera, and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents of which one may be bed ridden and the facility has an approved hospice waiver for four residence. Four residents are diagnosed with dementia and three residents are receiving hospice care services. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (4) resident bedrooms, (1) Full bathroom, 1 half restroom, living room, kitchen with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. The resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 115.1F – 116.4F. Residents bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. No bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

No Deficiencies cited:

An exit interview was conducted and a copy of report provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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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