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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320469
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:17:23 PM

Document Has Been Signed on 10/07/2024 04:17 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:HAPPY LIVING RELIABLE HOME LLCFACILITY NUMBER:
198320469
ADMINISTRATOR/
DIRECTOR:		CUELA, GLADYS T.FACILITY TYPE:
740
ADDRESS:109 EAST 232ND PLACETELEPHONE:
(310) 634-7501
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 0DATE:
10/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:Gladys Cuela, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 10/07/2024 at 09:15 am, Licensing Program Analyst (LPA) Zina Brown conducted an announced visit to the facility for purpose of a pre- licensing evaluation. LPA met with Gladys Cuela, Administrator)

An application was submitted to CCLD on 01/15/2024, for Initial license for an for an Residential Care Faciity for the Elderly (RCFE) to serve elderly residents and adults for all ages The requested capacity is for six (6) residents: five (5) non-ambulatory and (1) bedridden.

Structure:
Facility is a (6) bedroom, (2) bathroom, single story house with a attached garage with a washer and dryer, a receiving room, living room, a kitchen, a large backyard with a shaded patio area and a wheelchair at the main entrance of the facility. The client bedrooms are spacious and will easily accommodate the client's furnishings.

Signal system:
Signal system are installed throughout the facility.

Bedrooms Residents:
Bedrooms have been approved 5 non-ambulatory and one (1) bedridden.
Bedrooms # 1,2,4 are for (3) non-ambulatory. Bedroom # 3,5,6 (3) can be used for bedridden based on fire inspection. In all six (6) bedrooms has 1 bed, 1 chair, 1 night stands, 1 lamps with addition to overhead lighting. There is 1 dresser with three - four drawers, which comply with the requirement of 8 cubic feet of space.

Bathrooms:
Each bathrooms have a working toilet, wash basin, and shower. There is two (2) bathrooms that will accommodate non-ambulatory clients in a wheel chair.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HAPPY LIVING RELIABLE HOME LLC
FACILITY NUMBER: 198320469
VISIT DATE: 10/07/2024
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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads.

Emergency Phone Numbers, Exit Plan & Menu:
The facility has a working phone line and internet. Upon entering the facility to the left of the walkway, is a posted board that & readily available with a daily schedule of activites, community resources and consultants, sample meal menu. emergency information and personal rights for RCFE. Fire Extinguisher is located in kitchen and in the walkway mounted on wall which is fully charged.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer near the refrigerator. Food supply adequate stored in cabinet and consists can goods. The water temperature in the kitchen is at 117.6 F. Dishwasher in kitchen properly installed and functioning.

Smoke Detectors:
In the facility there are eleven (11) smoke detectors with carbon monoxide detectors that are electrical & connected. Battery operated & working.

Appliances:
In the facility is a working stove burners, oven, microwave, washer, and dryer. There is one (1) refrigerator in the kitchen that is measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. In the garage is washer and dryer which stores extra water and cleaning supplies.

Toxins:
All toxins are locked and stored in.

Water Temperature:
The water in each bathroom tested at 118.1 degrees Fahrenheit (bathroom 1), and 117.1 degrees Fahrenheit (bathroom #2).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HAPPY LIVING RELIABLE HOME LLC
FACILITY NUMBER: 198320469
VISIT DATE: 10/07/2024
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Pre-licensing Checklist: Completed by licensee and reviewed by LPA.

Component III:
During the conducted pre-licensing visit, an orientation of the component III information was provided to the licensee and employees about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA Zina Brown will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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