198320312-7-7-2023-11-AS-EDAT-CTHVJ3-20230707162803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320312
Report Date: 06/29/2023
Date Signed: 07/07/2023 04:28:21 PM

Document Has Been Signed on 07/07/2023 04:28 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CASA DEL SUR		FACILITY NUMBER:	198320312
ADMINISTRATOR:	AGATEP, EVANGELINE		FACILITY TYPE:	740
ADDRESS:	343 E 228TH STREET		TELEPHONE:	(310) 787-7300
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 6		CENSUS: 0	DATE:	06/29/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Glenda Bustos		TIME COMPLETED:	03:00 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	On 06/29/23, Licensing Program Analysts (LPAs) Ernand Dabuet and Ruby Velasco conducted announced visit to this home. LPAs was greeted by applicant Glenda Bustos and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 04/27/22 in the initial license application for a Residential Facility for the Elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which maybe three (3) non-ambulatory, (2) ambulatory, and one (1) bedridden. Structure: The home is a four (4) bedroom, two (2) bathroom, one story home with a two (2) car garage situated in a residential neighborhood. The home includes a living, a dining, a kitchen, and a laundry area. The living room does not include a fireplace. The living area included recliners and sofa. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility had four (4) bedrooms for residents. There are four (2) bedrooms for non-ambulatory (2) ambulatory residents and (1) of the bedrooms specific for the bedridden. All rooms include a twin-size bed, one (1) chair, one (1) night stand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DEL SUR	FACILITY NUMBER: 198320312
	VISIT DATE: 06/29/2023

NARRATIVE

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Fire clearance:
A Fire Clearance inspection was conducted on 06/02/23 approved for a capacity for three (3) non-ambulatory, two (2) for ambulatory, and one (1) for bedridden.

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

LPAs Dabuet and Velasco observed the following corrections:
· Incomplete First Kit
· No First Aid Manuel
· Room #1 window screen needs to be replaced
· Room #1 window covering needs to be correct size or replaced
· Room #4 cracked window located next to sliding door
· Room #2 screen door needs DW40 or replaced
· Required perishable food
· Thermometers for refrigerator & freezer
· Water Heater (no hot water)
· Stove front burner non-operable
· Facility Menu & Activity/Board Games

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Glenda Bustos . LPA Dabuet 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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DEL SUR	FACILITY NUMBER: 198320312
	VISIT DATE: 06/29/2023

NARRATIVE

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Bedrooms Staff:
Bedroom #1 is designated for live-in staff.

Bathrooms:
The home has two (2) bathrooms. Bathrooms are accessible in all rooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in each bedrooms.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are two (2) fire extinguisher located in the kitchen mounted on the wall and in the garage. A telephone line is available in the living room. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant submitted an approved Infection Control Plan.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer. Food supply is adequately stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide is available in living room.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet.

Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DEL SUR	FACILITY NUMBER: 198320312
	VISIT DATE: 06/29/2023

NARRATIVE

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Appliances:
Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which include a rice cooker and dish sanitizer. There is one (1) refrigerator in the home. The refrigerator appropriate food storage. The home is equipped with central heaters.

Water Temperature:
The water temperature was not available.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication cabinet inspected and found the kit to be incomplete and missing First Aid Manual. The resident's medications will be stored in the same medication cabinet locked in the kitchen and inaccessible.

Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in the kitchen cabinets.

Reading Material, Games, Equipment & Materials:
The materials were incomplete.

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

Evaluation Report Continues

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4