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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603126
Report Date: 07/05/2024
Date Signed: 07/08/2024 10:55:11 AM

Document Has Been Signed on 07/08/2024 10:55 AM - 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:ANL FACILITY HOME INCFACILITY NUMBER:
198603126
ADMINISTRATOR/
DIRECTOR:		BULOSAN, LUZVIMINDA AFACILITY TYPE:
740
ADDRESS:12073 HIGHDALE STTELEPHONE:
(562) 310-4871
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 5DATE:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Luzviminda BulosanTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced Required- 1 year visit. LPA Rea met with Administrator Luzviminda Bulosan and explained the purpose of the visit. The facility has a Dementia waiver, and a hospice waiver for 2 residents. Facility is a single story home located in a residential area consisting of 4 bedrooms (2 shared & 2 private), living room/dining area, kitchen, outdoor covered patio area, shed, and laundry area located in the backyard porch area. There is a detached garage in the rear of the property presently being used as storage and staff "resting area". The last emergency disaster drill was conducted on 6/11/2024. Administrator certificate expires 9/25/2024.

Facility was observed to be clean and in good repair. Temperature was between 68 degrees and 85 degrees Fahrenheit. All window screens were clean and in good repair. There was appropriate lighting in the facility and in each room. Protective devices were observed such as nonskid material on rugs. Indoor and outdoor passageways and stairways were free of obstructions. Stairways, inclines, ramps, open [porches and areas of potential hazard accessible to residents were well-lit and equipped with sturdy hand railings. The physical plant was consistent with the submitted facility sketch/floor plan.

Disinfectants, cleaning solutions, poisons and other items which could pose a danger to residents were observed to be locked and inaccessible. Fire alarms, smoke alarms and carbon monoxide detectors were tested and operate properly. Resident bedrooms are large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture, and any resident assistant devices such as wheelchairs or walkers if necessary. LPA observed a bed for each resident equipped with good springs, clean and comfortable mattress, pillow(s) and bedding. Bathroom floors were observed to be clean, sanitary and odorless. The hot water temperature measured between 113.1-117.5 degrees Fahrenheit. There was at least one toilet and sink for each six persons and one bathtub and shower for each ten persons. All bathtubs, showers and toilets had grab bars, and non-skid mats. All bathtubs, showers, toilets, and skinks operate properly.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
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: ANL FACILITY HOME INC
FACILITY NUMBER: 198603126
VISIT DATE: 07/05/2024
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 LPA observed there to be sufficient supply of hygiene items such as soap, and toilet paper. LPA also observed there to be sufficient supply of clean linen, including blankets, bedspreads, top sheets, bottom sheets, pillow cases, mattress pads, bath towels, hand towels, and was cloths, to permit changing weekly or more often as needed. Kitchen and dining room floors were observed to be clean, sanitary and odorless. Trash cans had tight fitting covers. The kitchen area was clean and free of litter. Cleaning supplies are kept in areas separate from food supplies. There is confidential storage area for personnel records, resident records and administrative files, which will be kept in a locked closed in the living room. There is a locked centralized storage are for resident medications, which are kept in the locked closet in the living room. The first aid kit, was observed by LPA to include sterile dressings, bandages, thermometer, scissors, tweezers and a current first aid manual. Emergency exit plans and telephone numbers; Facility Theft and Loss Program, Licensing Complaint Poster; Residential Personal Rights; Resident Council Rights were all observed to be posted. The facility has laundry supplies and equipment, which includes a washer and dryer. There is an operating telephone available for resident use. Emergency flashlights were observed. There are no bodies of water present.

There were no deficiencies cited. Exit interview conducted, and a copy of the report was provided to Ms. Bulosan.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC809 (FAS) - (06/04)
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