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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603461
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:11:11 PM

Document Has Been Signed on 06/16/2021 12:11 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:NEWCOMB GUEST MANORFACILITY NUMBER:
198603461
ADMINISTRATOR:GUEVARA, SUSANAFACILITY TYPE:
740
ADDRESS:10647 NEWCOMB AVETELEPHONE:
(562) 902-1943
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 6CENSUS: 0DATE:
06/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Applicant Susana Guevara TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an announced visit with applicant Susana Guevara. The purpose of the visit was to conduct the Pre-Licensing visit.

An application was submitted to CCLD on 3/13/2021, for a Change of Ownership of a Residential Care Facility for the Elderly for ages 60 years and older. The requested capacity of 6 residents, (0) ambulatory, (6) non-ambulatory and (0) may be bedridden and Hospice Waiver up to (6) residents.

Structure/Physical Plant:
The facility is part of a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) resident rooms, (1) live in staff rooms (2) bathrooms for residents and (1) bathroom for the live in staff; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to residents for storage and Laundry; with washer and dryer. The residence is equipped with air conditioning in each room. The facility is currently operating under facility # 198603329 and has 5 residents in the facility.

Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: Bedrooms #5 and #3 are for (1) non-ambulatory resident each . Bedroom #2 and #4 are for (2) non ambulatory clients. Bedroom #1 is used for live in staff. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: Bathroom #1, #2 and #3 have a working toilet, wash basin, shower, grab bars and nonskid mats.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2021
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: NEWCOMB GUEST MANOR
FACILITY NUMBER: 198603461
VISIT DATE: 06/16/2021
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Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There are (2) cordless phone for residents use. Fire Extinguisher 1 and 2 fully charged and up to date Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates are stored at the other location until residents move in. Knives, cutlery and other sharps inaccessible to residents will be kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working. Smoke detectors and also carbon monoxide detectors observed, all detectors tested and operational. (2) Fire extinguishers observed and up to date. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 110 -115 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to resident. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, which is available for staff use. Residents & Staff Files: Facility has a locked cabinet for resident and staff files. Sample files were observed. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 5/13/21.

During Visit Applicant was missing First Aid Manual but was purchased and proof was provided to LPA at time of visit. There are no corrections needed and physical plant is cleared.

Component III:
Component III was conducted at the time of this visit.

An exit interview was conducted over the tele-visit and a copy of this report has been furnished to the applicant Susana Guevara. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC809 (FAS) - (06/04)
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