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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603633
Report Date: 08/10/2023
Date Signed: 08/10/2023 03:00:10 PM

Document Has Been Signed on 08/10/2023 03:00 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:ALONDRA GUEST MANOR INCFACILITY NUMBER:
198603633
ADMINISTRATOR:KAYA, IWONAFACILITY TYPE:
740
ADDRESS:15203 ALONDRA BLVDTELEPHONE:
(714) 228-1098
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 0DATE:
08/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Applicant Iwona KayaTIME COMPLETED:
12:45 PM
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*** This report supersedes pre-licensing report dated 7/28/23. Purpose of the report is to remove and add correct fire clearance statements. There are no other changes***

Licensing program Analyst (LPA) Jose Villalobos conducted subsequent visit to correct initial statement from pre-licensing 7/28/23 report. LPA met with applicant Iwona Kaya and the purpose of the visit was discussed.

On 7/28/23 Licensing Program Analyst (LPA) Jose Villalobos conducted an announced visit with applicant Iwona Kaya. Applicant Stefanie Skormorucha was present via facetime. The purpose of the visit was to conduct the Pre-Licensing for the facility listed above.

An application was submitted to CCLD on 12/6/2022, 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 with approved fire clearance for up to (6) non-ambulatory residents. Approved Hospice Waiver up to (4) 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 room (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 # 198602532 and has 6 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:...
Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALONDRA GUEST MANOR INC
FACILITY NUMBER: 198603633
VISIT DATE: 08/10/2023
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*** This report supersedes pre-licensing report dated 7/28/23. Purpose of the report is to remove and add correct fire clearance statements. There are no other changes***

Bedrooms #1-#4 are for non ambulatory residents. Bedroom #5 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, and beds for each resident.Bathrooms: Bathroom #1, #2 have a working toilet, wash basin, shower, grab bars and nonskid mats.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 -120 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. First Aid Manual observed. Residents & Staff Files: Facility has a locked cabinet for resident and staff files. Current files for residents #1-#6 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 4/19/23.

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

An exit interview was conducted and a copy of this report has been furnished to the applicant Iwona Kaya. 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: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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