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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602974
Report Date: 12/01/2022
Date Signed: 12/01/2022 12:34:28 PM

Document Has Been Signed on 12/01/2022 12:34 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CERRITOS RESIDENCE CAREFACILITY NUMBER:
198602974
ADMINISTRATOR:NORA, PETERFACILITY TYPE:
740
ADDRESS:20111 GRIDLEY RDTELEPHONE:
(562) 809-3453
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 4DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Euphrosyne Dimaano - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met Euphrosyne Dimaano - Administrator and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents ages 60 and over, of which 1 may be bedridden, and may retain up to 6 hospice residents. The facility is operating within the scope of its license.

The facility is located in a residential area. A tour of the single-story facility included: 4 resident bedrooms, 2 bathrooms, living room, kitchen, dining area, attached garage, front yard, and backyard. LPA and Euphrosyne Dimaano toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 116.6 and 118.9 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in the hallway cabinets. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the hallway and it is properly operating. A fire extinguisher was observed in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Knives are kept locked under the kitchen sink. Cleaning chemicals are kept locked under the bathrooms' sinks. First Aid kit was fully stocked with current manual. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water. Passageways and exits are free of obstruction. Medication was
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CERRITOS RESIDENCE CARE
FACILITY NUMBER: 198602974
VISIT DATE: 12/01/2022
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Residents medication are centrally stored in a locked living room closet. Residents and staff files are centrally stored in the garage. LPA reviewed medication for all 4 of the residents and observed that medications are given as prescribed. LPA reviewed files for 4 residents and 4 staff and observed no deficiencies. LPA observed administrator certificate for Euphrosyne Dimaano - 6031893740 with an expiration date of 02/12/2024.

Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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