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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603671
Report Date: 09/01/2023
Date Signed: 09/01/2023 01:37:03 PM

Document Has Been Signed on 09/01/2023 01:37 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:JOYFUL HEARTS CARE HOMEFACILITY NUMBER:
198603671
ADMINISTRATOR:LOMEDA, RONAFACILITY TYPE:
740
ADDRESS:11648 FACULTY DRTELEPHONE:
(562) 219-7345
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 0DATE:
09/01/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Applicant- Rona LomedaTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an announced pre-licensing visit. LPA met with Applicant / Rona Lomeda for the purpose of conducting a pre-licensing inspection/ Component 3. A hospice waiver has been approved for a maximum of 6 terminally ill residents. Dementia plan of operation, Infection Control Plan and Bedridden plan was submitted to Centralized Application Bureau (CAB) Specialist and is/will be under review. The facility has an approved fire clearance for five (5) non-ambulatory residents and one (1) bedridden resident. Facility approved for total capacity of (6) six. The facility is a single story, five (5) bedroom, three (3) bathrooms (1 will be used for staff/visitors only), and has a detached garage. Home is located in a residential neighborhood in the City of Norwalk. Facility will be licensed to be a Residential Care for the Elderly, serving residents age range 60 and over.

-This facility was granted a fire clearance on 3/28/23.
-The physical plant was toured inside and out. At this time, LPA has determined that the home is ready and passed the pre-licensing inspection / Component 3.
-Facility tour alongside with Rona Lomeda / LPA used Pre-Licensed Inspection Tool.

LPA observed the following:
-Night lights and emergency lights in place and maintained throughout the facility.
-Passageways, stairways and doors are free of obstructions.
-Signal system in place on all exit doors.
-Bedrooms #1- #4 approved for non-ambulatory and Bedroom #5 approved for Bedridden.
-Water temperature in bathrooms, measured between 105F - 120F.
-Sufficient amount of towels and linens available to permit weekly changing, located in the hallway closet.
-Laundry machines (washer/dryer) located in the garage.
(Continuation on 809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: JOYFUL HEARTS CARE HOME
FACILITY NUMBER: 198603671
VISIT DATE: 09/01/2023
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-Emergency supplies, flash lights, medications/ medication book, first aid kit and manual, resident and staff files will/are maintained in the closet located between bedroom #1 and #2, and is inaccessible.
-Disinfectants, poisons, cleaning solutions are located locked under the kitchen sink cabinet.
-Sharps locked in kitchen cabinet.
-Pantry, cupboards, utensils, dishware, stove, kitchen counter, microwave, refrigerators are clean and in good condition.
-Refrigerator and Freezer observed to be clean and have thermometers in place.
-Small refrigerator near kitchen for future residents medication, kept locked.
-Required posting readily available: Facility Sketch , Emergency disaster plan, personal rights, Compliant Contact Information , labor information and ombudsman Contact information.
-All windows / window screens are cleaned throughout the home and facility is maintained in a clean, sanitary and safe condition.
-Smoke detectors and carbon monoxide were tested and are operable.
-Outdoor space is easily accessible, no obstructions, and no large bodies of water observed.
-Storage House (Shed) kept locked for garden supplies located in the backyard.
-Applicant Administration Certificate Expires: 10-06-23.
-Facility/ Licensee will be advertising once licensed, facility will comply with Section: 87706 Advertising Dementia Special Care, Programming, and Environments.
-Applicant Cell number: 562-569-8914


An exit interview was conducted and a copy of this report was provided to Applicant Rona Lomeda
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC809 (FAS) - (06/04)
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