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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320533
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:25:58 PM

Document Has Been Signed on 01/15/2025 12:25 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:FAMILY FIRST BOARD AND CARE IIFACILITY NUMBER:
198320533
ADMINISTRATOR/
DIRECTOR:		FAMISAN, ROSEMARIEFACILITY TYPE:
740
ADDRESS:2038 WEST 233RD STREETTELEPHONE:
(310) 910-6142
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 3DATE:
01/15/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Administrator Rosemarie FamisanTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Regina Cloyd conducted an announced visit to the facility for purpose of a prelicensing evaluation. An application was submitted to CCLD for change of ownership for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for six of which two may be non-ambulatory and four may be bedridden.

Structure:
Facility is a five-bedroom, two bathroom, single story house with a two car attached garage. The home has a fireplace in the family room with a metal screen cover and is inaccessible to clients. There is a large, covered patio area and a covered in-ground jacuzzi on the premises. The resident bedrooms are spacious and will easily accommodate the residents' furnishings. The passageways, walkways, and driveways are free from obstructions.
Bedrooms Residents:
There are no more than two residents per bedroom. Bedrooms #1, #2, #3, and #4 are for approved for bedridden residents. Bedroom #4 has two beds, two chairs, two nightstands, and two lamps in addition to overhead lighting. There is also a closet.
Bedrooms Staff:
Bedroom near the reception area is for staff.
Bathrooms:
All bathrooms have a working toilet, wash basin, bath-tub/shower. There are two bathrooms that will accommodate non-ambulatory clients in a wheelchair.
Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in the hallway closet.
Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY FIRST BOARD AND CARE II
FACILITY NUMBER: 198320533
VISIT DATE: 01/15/2025
NARRATIVE
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Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review on the wall in the reception area. There is a fire extinguisher located in the reception area and in the hallway.
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 next to the sink. Food supply adequate stored in the kitchen and in the garage consists of the following: perishables and non-perishables. Dishwasher in kitchen properly installed and functioning.
Carbon Monoxide & Smoke Detectors:
Battery operated & working.
Appliances:
Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators in the home, one in the kitchen and one in the garage for additional food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.
Toxins:
Locked and stored in the garage.
Water Temperature:
Tested at 110.9 F degrees.
Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the reception area, available for staff use but inaccessible to residents.
Clients & Staff Files:
Records of staff and residents shall be stored in a locked cabinet and the section has been inspected along with the available records present.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the residents' use, commensurate with the plan of operation.
LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
Page: 3 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY FIRST BOARD AND CARE II
FACILITY NUMBER: 198320533
VISIT DATE: 01/15/2025
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Fire clearance:
Fire Clearance with the following special conditions was approved on 09/18/2024.
Rooms approved for non-ambulatory/bedridden, approval of delayed egress or delayed egress with secured (locked) perimeter.
Pre-licensing Checklist:
Completed by licensee and reviewed by LPA.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA by 01/28/2025. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. Licensee to provide general liability insurance to meet the HSC 1569.605 requirement.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Centralized 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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