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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603358
Report Date: 03/10/2023
Date Signed: 03/10/2023 12:16:44 PM

Document Has Been Signed on 03/10/2023 12:16 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:SUPERCARE GUEST HOMEFACILITY NUMBER:
198603358
ADMINISTRATOR:JABONERO, JANICE RACHELLEFACILITY TYPE:
740
ADDRESS:13449 BIOLA AVETELEPHONE:
(714) 244-5885
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 6DATE:
03/10/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lalineth Escueta- CaregiverTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of following up on a Plan of Correction (POC) for deficiencies cited during the annual inspection visit, conducted on 03/07/2023. LPA Maldonado met with caregiver Lalineth Escueta and explained the purpose for the visit.

On 03/07/23, LPA Maldonado observed a resident with dementia (R1) to be residing in a detached bedroom located in the back yard, that that did not have proper fire clearance for non-ambulatory residents, which posed an immediate health, safety or personal rights risk to persons in care.

During today's visit, LPA conducted a tour of the physical plant with Lalineth. The outside, detached bedroom was observed to be vacated, with only a TV left on the floor and a chest full of drawers. Lalineth stated those items will be taken out once additional space is made in the garage for storage- all of the R1's personal items have been taken to their new room. LPA also observed R1's items in room# 1 inside the home, that was initially observed to be a private bedroom during LPA's initial visit, on 03/07/23. This room was noted to have proper fire clearance for non-ambulatory residents. LPA observed 6 residents in the home during the visit, including R1. No immediate health and/or safety concerns were observed during today's visit.

Per California Code of Regulations, Title 22 and Health and Safety Code, no deficiencies were cited during today's visit and the POC will be cleared.

An exit interview was conducted and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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