198320262-3-30-2022-11-AS-GJON-CCZVSU-20220330164207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320262
Report Date: 03/30/2022
Date Signed: 03/30/2022 04:42:21 PM

Document Has Been Signed on 03/30/2022 04:42 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	FLORESMA GUEST HOME		FACILITY NUMBER:	198320262
ADMINISTRATOR:	SERRANO, CARL		FACILITY TYPE:	740
ADDRESS:	1812 E. HARDWICK AVE		TELEPHONE:	(562) 895-2418
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY: 6		CENSUS:	DATE:	03/30/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Myrna Ma		TIME COMPLETED:	04:50 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	03/30/22, Licensing Program Analysts (LPA) Gail Johnson conducted an announced visit to this home. LPA was greeted by applicant Myrna Ma, and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 02/12/22. In the initial license application for a Residential Facility for Adults, ages ranging from 60 and older. Fire Safety Inspection Request granted this facility approval to care for three (3) ambulatory and three (3) non-ambulatory residents. Structure: This is a pink colored one-story home and is located in a residential neighborhood. The home includes six (6) bedrooms, two (2) bathrooms, a living and dining area, two (2) kitchens, two (2) family rooms, two (2) staff bedrooms, and laundry area (in the garage). The resident living area includes a sofa, recliner, and television. The kitchen has a laminate countertop, refrigerator and stove. The rear exterior is fenced throughout. Passage-ways, walk-ways, and steps are free from obstructions. Bedrooms Clients / Bedrooms Staff Clients reside in four (4) bedrooms. The bedrooms are labeled numbers three (3), four (4), five (5) and six (6). There are two (2) bedrooms for ambulatory clients and (2) two bedrooms for non-ambulatory clients. All rooms include (1) a full-size bed, one (1) chair, one (1) nightstand, one (1) table lamp. All bedrooms are equipped with sufficient lighting. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets/and or ample storage space. Two bedrooms are occupied by staff. These rooms are sectioned from the other half of the house, and utilized as staff areas. Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FLORESMA GUEST HOME	FACILITY NUMBER: 198320262
	VISIT DATE: 03/30/2022

NARRATIVE

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(1)Bathrooms (2) Linens & Hygiene Supplies (3) Emergency Phone Numbers and Menu:
(1)The home has two (2) bathrooms. Two (2) bathrooms are located in the same resident portion of the home. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.
(2)Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in common area near bathroom.
(3) Emergency phone numbers. The menu is posted and readily available for review throughout the home. There are two (2) fire extinguishers located in the dining area, mounted on the wall and fully charged.

(1)Food Service (2) Smoke Detectors (3) Toxins
(1) Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are in a locked cabinet. Food supply is stored in kitchen cabinets and consists of can goods. The kitchen counters also had small appliances.
(2) Smoke and carbon monoxide detectors are located throughout the interior space. Smoke detectors and carbon monoxide detectors are interconnected in all hallways and common areas. Smoke detectors are in all four (4) bedrooms.
(3) All toxins are locked/stored inside the kitchen hall closet.

(1)Appliances (2) Water Temperature (3) Medications, First-Aid Kit & Book (4) Staff Records
(1) Stove burners, oven, microwave, washer, and dryer are all working. The kitchen counters also had small appliances which include a toaster, blender, and coffee maker. There is one (1) refrigerator inside the home. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. The residence is equipped with central air and heat.
(2) The water temperature is 106.8 degrees Fahrenheit throughout the kitchen and bathrooms.
(3)A first aid kit is stored in a cabinet that has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to clients. The client's medications will be stored in a cabinet locked and locked near the kitchen and inaccessible to clients.
(4)Records of staff and clients will be in a shelving area in the office

Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FLORESMA GUEST HOME	FACILITY NUMBER: 198320262
	VISIT DATE: 03/30/2022

NARRATIVE

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Reading Material, Games, Equipment & Activities:
The facility has board games, books, magazines, puzzles, and other activities for the client's use all stored in the family room (under the televion) All activities are for client use and align with the plan of operation.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Fire clearance:
A Fire Clearance inspection was conducted on 02/8/22 with approval for a capacity for two (3) ambulatory, two (3) for non-ambulatory.

Component III:
LPA Johnson conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

Requirements for Pre-License Approval (Please submit the following) by Friday, April 15, 2022:
(1) Accurate facility sketch that labels each portion of the home (including staff living room, kitchen, and all portions/rooms of the inside and exterior of the home.
(2) Evidence of working telephone (Applicant will email receipt with phone number, and picture of the phone in the family room).
(3) Applicant will email picture of umbrella, table and chairs in the backyard.

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Myrna Ma. LPA Gail Johnson will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

>END OF REPORT<

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

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