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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602860
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:06:44 PM

Document Has Been Signed on 04/28/2022 01:06 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:LITTLE VILLAFACILITY NUMBER:
198602860
ADMINISTRATOR:HENG, SANG AFACILITY TYPE:
740
ADDRESS:3040 E. EDDES STREETTELEPHONE:
(213) 910-0442
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 0DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sang Heng (Administrator)TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Sang Heng (Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 60 and over. 6 non-ambulatory of which 1 is bedridden. Hospice waiver for 3.

A tour of the facility contains the following: Living room, dining area, kitchen, 3 bedrooms, 2 bathrooms and an attached garage.

During today's visit, LPA observed the following: Currently the facility does not retain residents. The bathrooms are clean and operational. Clients bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested and measured at 118.4 degrees F in bathroom #1. The kitchen was observed for the ability to prepare and serve food. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed fully charged. The first-aid kit is fully stocked w/First-aid Manual. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Sang Heng.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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