<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602174
Report Date: 08/26/2022
Date Signed: 08/26/2022 04:43:46 PM

Document Has Been Signed on 08/26/2022 04:43 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALLEN'S PALM COVE CERRITOSFACILITY NUMBER:
198602174
ADMINISTRATOR:DIMAANO, EUPHROSYNEFACILITY TYPE:
740
ADDRESS:18714 KINGS ROW AVETELEPHONE:
(562) 866-3585
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 4DATE:
08/26/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Euphrosyne Dimaano & Peter NoraTIME COMPLETED:
04:58 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
Licensing Program Analyst (LPA) David Sicairos and Regional Manager (RM) Araceli Ramirez conducted a Case Management follow up visit to follow up on the items discussed during the Case Management visit conducted on 08/24/22. LPA and RM met with Direct Support Staff Rebecca Blake and explained the reason for the visit. Administrators Euphrosyne Dimaano and Peter Nora arrived shortly thereafter.

Administrators notified LPA and RM that R1's Physician came to the facility to assess him today. Per Administrators, Physician recommended a higher level of care (Skilled Nursing Facility). According to Administrators Physician will be following up with R1 at a later date. R1's Case Manager will be working with Administrators to initiate R1's transfer to a Skilled Nursing Facility per Physician's recommendations. R1 is in agreement with the transfer, R1 disclosed a Skilled Nursing Facility of choice. LPA and RM also discussed with Administrators the importance of providing timely services on a as needed basis for R1 while a resident of the facility. Administrators were reminded that they are responsible for the care and supervision of the resident for as long as he is a resident of the facility. LPA, RM, along with Administrator Euphrosyne had a discussion with R1 regarding the following steps moving forward in transferring him to the Skilled Nursing Facility of choice.

LPA reviewed Administrator's file and obtained copies of the following documents: current Administrator Certificates, and Employee Training Records. Administrator will email R1's updated Care Plan.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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 1