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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603572
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:13:50 AM

Document Has Been Signed on 09/20/2022 11:13 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PALAZZO OF DOWNEY, INC., THEFACILITY NUMBER:
198603572
ADMINISTRATOR:CARRILLO, ROWENA MARANTALFACILITY TYPE:
740
ADDRESS:9276 DOWNEY AVETELEPHONE:
(562) 659-7586
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 6CENSUS: 0DATE:
09/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Rowena Marantal Carrillo - LicenseeTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an announced pre-licensing visit. LPA met with Rowena Marantal Carrillo (Licensee) and explained the reason for the visit. The home is located in a residential neighborhood in the city of Downey and it is a two story building. The downstairs consists of 2 resident bedrooms, 2 resident bathrooms, 2 living room, dining area, kitchen, laundry room, and attached garage. The upstairs consists of 4 resident bedrooms, 3 resident bathrooms, 1 staff bedroom, and 1 living room. The home has a fire clearance from the local Fire Department for a capacity of 6 ambulatory residents ages 60 and over.

LPA Mora conducted the tour with Rowena Marantal Carrillo and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept locked in a kitchen cabinet. The First Aid kit is kept locked in a kitchen cabinet and it is fully stocked with all required items including a current manual. Medications will be centrally stored in a locked kitchen cabinet. Cleaning and chemical solutions are kept locked in the laundry room and under the kitchen sink. Dining and living room have sufficient lighting and sitting area. All bedrooms have all required furniture, lighting, and bedding. There is clean linen in each bedroom closet. There are clean towels in the laundry room. All bathrooms were observed with non-skid material and grab bars. The water temperature was tested in all 5 resident bathrooms and it measured at 105 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in each floor, and both were fully charged. Smoke detectors were observed in each bedroom and throughout the facility and were operable during the visit. A carbon monoxide was observed in each floor and were operable during the visit. Resident and staff files will be kept locked in a laundry room cabinet. All exit doors have an auditory device and was operable during the visit. The facility has a stair lift chair that was operable during the visit. The front yard and backyard are clean, and there is a shaded sitting area in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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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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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572
VISIT DATE: 09/20/2022
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No outstanding or pending items were observed by the LPA requiring additional pre-licensing visits. LPA 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 to the Administrator.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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