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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603193
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:58:51 PM

Document Has Been Signed on 12/11/2023 03:58 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:CERRITOS ASSISTED LIVINGFACILITY NUMBER:
198603193
ADMINISTRATOR:SANTA ANA, OSVALDOFACILITY TYPE:
740
ADDRESS:18511 KAMSTRA AVENUETELEPHONE:
(562) 637-3392
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 4DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:AdministratorTIME COMPLETED:
04:13 PM
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On 12/11/23 at 1:20 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Cerritos Assisted Living. Upon arrival LPA was greeted by the Administrator, Runette Catibog, and LPA explained the reason for the visit. This home is licensed to serve age range 60 and over. Approved for 6 Non- Ambulatory, of which 1 may be bedridden. Approved hospice waiver for 2. There were (4) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 12/6/2023.The Administrator Certificate expired on 10/26/2023 #6011129740. LPA observed the Administrators named listed on the pending list on the CDSS website. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (4) resident files, medications, and medication administration records for (4) resident.

This home contains 3 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (3) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 111.3*F-117.1*F. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located, tested, and functioning properly. There were (1) fire extinguishers located in the dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked underneath kitchen sink with cleaning agents and toxins. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CERRITOS ASSISTED LIVING
FACILITY NUMBER: 198603193
VISIT DATE: 12/11/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained with chairs. The back yard was also well maintained with two shaded seating area accessible for resident use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the residents.

The dining room contained a fireplace that was locked from beneath the fireplace.

The facility contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

Exit interview conducted with Runette Catibog , Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
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