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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603581
Report Date: 01/11/2023
Date Signed: 01/11/2023 11:42:38 AM

Document Has Been Signed on 01/11/2023 11:42 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALL WE NEED IS LOVE RESIDENTIAL CAREFACILITY NUMBER:
198603581
ADMINISTRATOR:MIRABUENO, BUENOMIRFACILITY TYPE:
740
ADDRESS:5340 KIRTLAND AVETELEPHONE:
(312) 646-9252
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 6CENSUS: 4DATE:
01/11/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marilyn Mirabueno - LicenseeTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an announced Pre-Licensing visit. LPA met with Marilyn Mirabueno (Licensee) and Buenomir Mirabueno (Administrator) and explained the reason for the visit. A change of ownership application was submitted to Community Care Licensing Department (CCLD) for a Residential Care Facility for the Elderly (RCFE) to serve 6 non-ambulatory residents, in which 1 may be bedridden, in the age range of 60 and over. Facility is approved for 6 hospice waivers.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the 4 resident bedrooms, 1 staff room, 2 bathrooms, living room, kitchen, laundry room, attached garage, front yard and back yard. LPA Mora conducted the tour with Marilyn Mirabueno 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. Kitchen appliances are clean and were operating at the time of the visit. Sharps were observed locked in the medication cabinet. Chemical and cleaning solutions are kept locked in the laundry room and bathrooms. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway closet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a kitchen cabinet. All bedrooms have all required furniture, lighting, and bedding. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The showers have non-skid materials. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 114.4 degrees F and 114.0 degrees F, which is within the required 105-120 degrees F. Fire extinguishers were observed in the kitchen and garage, and are fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. Fireplace has a screen cover. Resident and staff files are kept locked in a living room cabinet. (CONTINUED TO LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALL WE NEED IS LOVE RESIDENTIAL CARE
FACILITY NUMBER: 198603581
VISIT DATE: 01/11/2023
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LPA reviewed medication for all 4 of the residents and observed that medications were given as prescribed. LPA reviewed files for all 4 of the residents and observed no deficiencies. LPA reviewed 4 staff files and observed no deficiencies. LPA observed an administrator certificate for Buenomir R Mirabueno – 6054728740 with an expiration date of 12/29/2023.

Facility has 30 days supplies of Personal Protective Equipment in the laundry room. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

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: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC809 (FAS) - (06/04)
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