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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603464
Report Date: 08/12/2021
Date Signed: 08/12/2021 12:26:53 PM

Document Has Been Signed on 08/12/2021 12:26 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:AMELIA ROSE SENIOR CARE COTTAGEFACILITY NUMBER:
198603464
ADMINISTRATOR:DALLAS, CHERYL Y.FACILITY TYPE:
740
ADDRESS:3210 WOLFE STTELEPHONE:
(310) 438-3978
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 6CENSUS: 0DATE:
08/12/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cheryl Dallas (Administrator)TIME COMPLETED:
12:40 PM
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Licensing Program Analysts (LPAs) Luis Mora & David Sicairos conducted an announced pre-licensing visit. LPAs met with Cheryl Dallas (Administrator) and explained the reason for the visit.

The home is located in a residential neighborhood in the city of Lakewood and is a one story building which consists of five (5) resident bedrooms, three (3) bathrooms, living room, dining room, kitchen, laundry room, and attached garage. The home has a fire clearance from the local Fire Department for a capacity of five (5) non-ambulatory and one (1) bedridden residents ages 60 and over.

The following was inspected during the visit with the Administrator. A locked cabinet area for central storage of medications was observed in the laundry room. Cleaning supplies were separate from where food supplies are stored. The walls, ceilings, floors, window screens and areas around the facility were clean and in good repair. A locked cabinet area above the washer and dryer for cleaning products and disinfectants was observed. Three (3) fire extinguishers were observed in the facility. Smoke detectors and carbon monoxide detectors are hardwired and were observed throughout the facility which were tested and operable. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris. No pools or bodies of water were observed in or around the home. There are no firearms present at the facility.

Required postings were observed to be posted in appropriate places. A current disaster and mass casualty plan is maintained at the facility. An operating telephone was observed in the living area, which is easily accessible and available for client use.

The first-aid kit was observed and is kept in a locked cabinet located in the laundry room, which included all required supplies. The refrigerator was observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit. (CONTINUED ON 809C)
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMELIA ROSE SENIOR CARE COTTAGE
FACILITY NUMBER: 198603464
VISIT DATE: 08/12/2021
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Food storage and preparation areas, which includes pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwave, refrigerator, and stove were observed to be clean and operating properly. Food utensils were clean and sufficient for the number of clients to be served.

All rooms were observed to be appropriately furnished for their intended use and were client appropriate. The hot water temperature was measured in bathroom #3 and measured at 105.2. The outdoor patio in the backyard was observed to have well shaded area and was furnished for outdoor use. Each residents bedroom was observed to have a mattress, pad, bedsprings, and a pillow which were clean. The resident bedrooms have adequate dresser and closet space for clothing and other belongings.

A sufficient supply of linens to permit weekly changing or more often to insure clean linens at all times for clients were observed to be kept in the hall linen closet. Personal hygiene supplies were observed readily available for resident use. Activity supplies were observed and readily available for residents. Employee and resident records will be maintained and locked in the storage room.

No outstanding or pending items were observed by LPA requiring additional pre-licensing visits. LPA Mora will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC809 (FAS) - (06/04)
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