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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603676
Report Date: 10/15/2024
Date Signed: 10/15/2024 11:28:06 AM

Document Has Been Signed on 10/15/2024 11:28 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:FELSON BOARD AND CAREFACILITY NUMBER:
198603676
ADMINISTRATOR/
DIRECTOR:		TANGONAN, MARIA ISABELFACILITY TYPE:
740
ADDRESS:13639 FELSON STREETTELEPHONE:
(562) 307-7668
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator Isabel TangonanTIME VISIT/
INSPECTION COMPLETED:
11:42 AM
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On 10/15/2024 Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced annual inspection. Upon arrival LPA met with Direct support Professional (DSP) Christyna Blanco. Staff contacted the Administrator and LPA explained the reason for the visit. The Administrator Isabel Tangonan arrived at 9:17 am to assist with the visit.

The facility has an approved fire clearance to be licensed to serve residents aged 60 and above, six (6) non-ambulatory, and (1) of which may be bedridden. Bedrooms 2 and 3 are allowed 1 non ambulatory each. Bedroom 1 is allowed 2 non ambulatory. Bedroom 4 is allowed 1 non ambulatory and 1 bedridden. Hospice waiver approved for six (6). The facility is a single-story home: 4 bedrooms, 1 staff bedroom, 2 bathrooms, dining room, living room, kitchen, backyard, and an attached garage. Administrator certificate # 7020686740 expired 10/30/2025. Emergency disaster drill last conducted 10/04/2024. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (6) resident files, medications, and medication administration records for (6) residents.

All (6) resident bedrooms contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, shower with grab bar, shower chair, and bathmat. The temperature measured at 113.0*F-113.3*F. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguisher located in kitchen and garage fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked in Kitchen cabinet. The cleaning agents and toxins were locked underneath kitchen sink. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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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: FELSON BOARD AND CARE
FACILITY NUMBER: 198603676
VISIT DATE: 10/15/2024
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The outdoor grounds were toured and inspected, and the patio was well maintained with shaded seating area accessible for resident’s use. The garage contained cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, washer and dryer, toxins and cleaning agents stored locked and inaccessible to the residents.

The entrance contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, and community resources.

Exit interview conducted with Isabel Tangonan, Administrator, a copy of this report was provided via email.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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