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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603657
Report Date: 09/26/2023
Date Signed: 09/26/2023 11:30:52 AM

Document Has Been Signed on 09/26/2023 11:30 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:HOME 'R USFACILITY NUMBER:
198603657
ADMINISTRATOR:ISIDRO, MARGARITAFACILITY TYPE:
740
ADDRESS:10423 TRABUCO ST.TELEPHONE:
(562) 376-0298
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 6CENSUS: 0DATE:
09/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Margie Isidro - Licensee/ApplicantTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Bennette Pena conducted an announced subsequent pre-licensing inspection and met with Applicant/Licensee Margie Isidro. The facility will be licensed as a Residential Care Facility for the Elderly, age range 60 and over to serve six (6) ambulatory residents, of which two (2) may be non-ambulatory in bedroom #1. Accessory Dwelling Unit (ADU) in the back is for staff use only. There are currently 0 residents in care.

During today's visit, LPA performed a final walk through and toured the facility with the Applicant.
LPA observed the following items that have been corrected:
  • Hot water temperature needs to be adjusted and must meet the Title 22 Regulations requirements of hot water reading to be between 105-120 deg F. : At 10:39am, LPA measured hot water temperature and water temperature readings ranged between 106.5-109.9 deg F.
  • Install grab bars and nonskid mats in the shower room in Bathroom #1. : Grab bars and nonskid mats in bathroom #1 have been installed.
  • Need a safe container to dispose syringes and needles in accordance with the Title 22 Regulations 87303 (g)(1) : Applicant purchased a small sharps container.
  • The laundry machines are in the attached garage and has a very tight space. Submit a plan to make the laundry area accessible and safe for residents. : Applicant cleared the space around the laundry machines and are now easily accessible to use for future residents.
  • Get mattress pads for the beds in bedrooms 3 & 4. : Applicant has purchased the mattress pads/covers for all (4) mattresses in bedrooms 3 & 4.
  • Install carbon monoxide.: Carbon monoxide has been installed in the kitchen/dining area. Applicant stated she will purchase a few more to be installed in the hallway and living room.
  • Install auditory devices in exit points and the doorbell in the front door. : Applicant installed the auditory devices in exit points.
  • Stock up on additional PPE supplies. : Applicant purchased additional PPE supplies.
  • Clear the side yard of the unused bulk items. : Side yard has been cleared.
  • Clear the front yard of parked vehicles to provide clear access.: Front yard has been cleared.
  • Lock the cleaning solutions stored in the cabinet under the sink in the 1/2 bathroom. : Cleaning solutions in the cabinet under the sink in the 1/2 bathroom has been locked and made inaccessible to future residents.
  • Designate an area/place to store the medications for residents. It must be locked, secured and inaccessible to residents. : Applicant designated one of the kitchen cabinets to be the medication cabinet which is locked and inaccessible to future residents.
  • Applicant must purchase liability insurance.: No current liability insurance, according to CAB Analyst Ricmar Soriano, liability insurance is not a requirement for licensure. Applicant stated she will purchase the liability insurance once she receives her RCFE license.
  • The following needs to be posted in a visible location in the home:
I. Theft and Loss policy
II. Visitation policy
III. Contact information/list of emergency agencies/Emergency exiting plans
IV. Labor information
- All policies/information have been posted near the entrance area.

The Pre-licensing deficiencies have been resolved. Pre-licensing is now complete.

An exit interview was conducted, and a copy of this report has been provided to Margie Isidro, Applicant/Licensee. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the Applicant/Licensee has questions regarding the status of the application, they have been instructed to communicate with their assigned CAB Analyst.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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