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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603657
Report Date: 11/22/2024
Date Signed: 11/22/2024 02:52:37 PM

Document Has Been Signed on 11/22/2024 02:52 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOME 'R USFACILITY NUMBER:
198603657
ADMINISTRATOR/
DIRECTOR:		ISIDRO, MARGARITAFACILITY TYPE:
740
ADDRESS:10423 TRABUCO ST.TELEPHONE:
(562) 376-0298
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 6CENSUS: 2DATE:
11/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Margie Isidro - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to follow up on a citation that was issued on 10/26/24 during the facility's Annual Inspection. LPA met with Administrator Margie Isidro who assisted with the visit.

On 10/26/24 the facility was cited for the following:

87204(a) - Limitations - Capacity and Ambulatory Status - (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

On 11/17/24 LPA received photos of R1 to be in what appeared to be Room #1 which is the only room in facility that is Fire Clearance Cleared for non-ambulatory residents and meets the non-ambulatory status that R1 has.

During todays visit 11/22/24 LPA toured Room #1 and observed R1's belongings in room and R1 also in room. R1 confirmed they have moved into Room #1. Room #3 was also toured and there were no longer any of R1's belongings observed in room.

The POC was reviewed at the time of visit and was deemed sufficient to clear.



Exit interview held. A copy of the report and copy of Cleared Deficiency Letter was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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