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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603666
Report Date: 08/04/2023
Date Signed: 08/04/2023 11:04:57 AM

Document Has Been Signed on 08/04/2023 11:04 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:QFC LOVING CARE INC., LAJARAFACILITY NUMBER:
198603666
ADMINISTRATOR:AGAS, VIRGILIOFACILITY TYPE:
740
ADDRESS:10710 LA JARA STREETTELEPHONE:
(818) 599-3115
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 0DATE:
08/04/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Hegine AbeshyanTIME COMPLETED:
11:20 AM
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On 8/4/2023 at 9:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an announced pre-licensed visit and met with Applicant Hegine Abeshyan for the purpose of conducting a Pre-Licensing Inspection / Component III visit. The facility has an approved fire clearance to be licensed to serve four (4) ambulatory, (1) non-ambulatory, and (1) bedridden Residents age 60 and above. The facility is a single-story home: 3 bedrooms, 2 bathrooms, dining room, living room, kitchen, laundry room, nook, backyard and an attached garage.

The physical plant was toured inside and out alongside applicant Hegine Abeshyan. Pre-Licensed Inspection Tool was used.

The following was observed/inspected.

· Each bedroom is designated as a private bedroom. Bedrooms are equipped with one bed, night stand, chair, sufficient lighting, appropriate closet, and drawer space.


· All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Mattresses and bedsprings are in good repair.
· Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
· Sufficient supply of linens available to permit weekly changing and are stored in storage cabinet.
· Sufficient personal hygiene supply available.
· Laundry machine (wash/dryer) observed.
· All (2) bathrooms have a working toilet, wash basin, and showers. All showers have a grab bars and non-skid mats.
· There are enough bath towels, hand towels and wash cloths for all clients.
Continuation on 809-C...
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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: QFC LOVING CARE INC., LAJARA
FACILITY NUMBER: 198603666
VISIT DATE: 08/04/2023
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·Smoke Detectors and Carbon monoxide detectors are interconnected approved in the Fire Clearance.
· Two (1) Fire extinguishers observed and charged.
· Cleaning solutions and sharps are locked in kitchen and only accessible to staff.
· Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher is in working condition, clean and sanitary.
· Food Menu Samples observed.
· Sufficient dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair.
· The facility has sufficient dining tables and chairs.
· There is a designated space for Medications to be locked and inaccessible to clients, stored in the kitchen cabinets.
· Residents and Staff files will be stored and locked in designated file cabinet.
· First Aid Kits observed with manual.
· Physical plant is in good repair.
· Building and grounds are free from hazards.
· Window screens are in good condition.
· Shaded area provided in the backyard to accommodate clients; no bodies of water observed.
· Hot water temperature measured at 114.8 F- 115.1 F, within Title 22 regulation.
· The residence is equipped with central air and heating, temperature remained at a comfortable temperature.
· Facility land line operable, facility number: (562)474-1076
· Variety of activity supplies for clients observed.
· Licensee reports no guns or weapons in the home.
· Delayed egress observed. Fire clearance approved of delayed egress/secured perimeter/secure locked perimeter.

Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility met the physical plant requirements/ inspection as required per California Code of Regulations Title 22 Division 6.

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.



Exit interview conducted and a copy of this report was provided to Applicant Hegine Abeshya
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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