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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603247
Report Date: 12/09/2021
Date Signed: 12/10/2021 08:43:47 AM

Document Has Been Signed on 12/10/2021 08:43 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EVERLASTING HOME CAREFACILITY NUMBER:
198603247
ADMINISTRATOR:BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:5413 BROCKWOOD STREETTELEPHONE:
(562) 421-4855
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 6DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Maria MiclatTIME COMPLETED:
04:30 PM
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On 12/14/21, at 3:04 pm, Licensing Program Analyst (LPA) Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was allowed entry into the facility by Maria Miclat, Caregiver. LPA met with Ms. Miclat and explained the purpose of the visit. The facility is licensed to operate age range 60 and over six (6) ambulatory residents of which 6 may be non-ambulatory and hospice waiver for 3.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) bedrooms, (2) bathrooms, living room, family room, dining room, kitchen, two car garage/ storage, and back yard with umbrella, table and chairs. LPA toured the physical plant with Ms. Miclat. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.9 degrees Fahrenheit. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. Fire Drills were observed to be maintained in order and accurate.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: EVERLASTING HOME CARE
FACILITY NUMBER: 198603247
VISIT DATE: 12/09/2021
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Maria Miclat.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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