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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602967
Report Date: 02/03/2023
Date Signed: 02/03/2023 01:06:22 PM

Document Has Been Signed on 02/03/2023 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:DREAM CARE HOME LLCFACILITY NUMBER:
198602967
ADMINISTRATOR:CASTRO, MONAFACILITY TYPE:
740
ADDRESS:11838 163RD STTELEPHONE:
(562) 404-7010
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 4DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator- Mona CastroTIME COMPLETED:
01:15 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) Ashley Calderon conducted a unannounced annual inspection. LPA met with Caregiver Pedra Grysson and discussed the purpose of todays visit.

LPA requested staff and resident roster, facility sketch, and liability insurance. LPA Calderon alongside with Pedra toured the physical plant. The single story house has an attached garage. LPA toured the kitchen, dining room, living room, 1 resident bathroom, 1 staff bathroom inaccessible to clients. Three resident rooms, 1 staff room. Additional room was observed, room #4, facility requested capacity increase (pending), paperwork submitted to LPM Lisa Hicks via mail on Aug 2022. Room #4 is vacant, locked and inaccessible to residents. LPA Calderon observed inside and outside of the facility premises, facility maintained clean, free of debris and obstructions. The common bathroom is clean and operational with grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables, extra food storage, freezers and refrigerators in the garage. Storage areas for cleaning solutions, toxic, and hazardous items were secured and made inaccessible to residents stored in garage. Knives are maintained in the kitchen and are kept locked. No residents on Hospice at the moment, approved for 2. The facility fire alarms are hard wired and interconnected to the Los Angeles Fire Department, carbon monoxide were tested and are operable. The fire extinguisher is located in the kitchen and is fully charged and meets regulations. The first-aid kit is fully stocked w/First-Aid Manual, thermometer, scissors, tweezers, bandages and sterile first-aid dressing. There is a functioning telephone on the premises and there are emergency lighting, such as flashlights and night lights. The facility has central air and heating accommodations. The washer and dryer are located in the garage which is next to the kitchen.
Continuation on Page 9099-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DREAM CARE HOME LLC
FACILITY NUMBER: 198602967
VISIT DATE: 02/03/2023
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
26
27
28
29
30
31
32
All required information (PUB 475, Emergency Exiting Floor Plan, Personal Rights, Ombudsman Information, Theft and loss policy and Emergency Telephone Numbers) are posted in the facility. At 9:45 am LPA met with Administrator Mona Castro. LPA alongside with Castro reviewed residents medication and Medication Record Log, LPA observed medication stored properly and documented. LPA reviewed resident files, total of 6. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. LPA observed sufficient PPE, Covid-19 Posters and Health Screening log.

Liability insurance expires 2/7/2023 and will be renewed. The Administrator's certificate is current and expires on 8/31/2023.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit.

An exit interview was conducted and copy of the report was provided to the Administrator.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2