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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603461
Report Date: 06/27/2022
Date Signed: 06/27/2022 04:40:45 PM

Document Has Been Signed on 06/27/2022 04:40 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: 4DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Iwona Kaya TIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Iwona Kaya. The purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (4) resident records, (4) staff files, and (4) resident medications. Currently the facility has (4) residents which (4) are non-ambulatory. Facility is a one story family home with four (4) client bedrooms, one (1) bedroom for live in staff, three (3) bathrooms, living room, kitchen, central air and heating, dining area, laundry room, a shaded area located in the backyard. an attached garage inaccessible to residents. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#4 required furnishing. Bathroom have a working toilet, wash basin, and shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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