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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603697
Report Date: 02/27/2024
Date Signed: 02/27/2024 03:06:30 PM

Document Has Been Signed on 02/27/2024 03:06 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:CERRITOS CHRISTIAN HOMEFACILITY NUMBER:
198603697
ADMINISTRATOR:TRICE, THOMASFACILITY TYPE:
740
ADDRESS:12033 CAMINO VALENCIATELEPHONE:
(562) 397-2591
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 5DATE:
02/27/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator Thomas Trice TIME COMPLETED:
03:22 PM
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On 2/27/24 at 11:25 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Post Licensing inspection to Cerritos Christian Home. Upon arrival LPA was greeted by direct care professional (DSP) who then contacted Administrator Thomas Trice. The Administrator Thomas Trice arrived at 11:40 a.m., and LPA explained the reason for the visit. This home is licensed to serve age range 60 and over. Approved fire clearance for six (6), of which one (1) may be bedridden and five (5) may be non-ambulatory. Bedridden cleared in bedroom #4. Waiver granted for hospice care for five (5). There were (5) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 12/18/2023. The last fire inspection was conducted on 1/23/24. The Administrator Certificate expires on 12/01/2024 #6048147740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (5) resident files, medications, and medication administration records for (5) resident. LPA also reviewed personal policies, abuse reporting procedures, in-service training, and medication training.

This home contains 4 bedrooms, 2 bathrooms, living room with fireplace, 1 break room/storage, kitchen, dining room, and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 109.5*F. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (1) fire extinguishers located in the dining room 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 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: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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: CERRITOS CHRISTIAN HOME
FACILITY NUMBER: 198603697
VISIT DATE: 02/27/2024
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The outdoor grounds were toured and inspected the patio; it was well maintained with a shaded seating area accessible for resident use. The garage contained cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, PPE’s, activity supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The living room contained playing cards, board games and activity supplies available to the residents and non- working fireplace with cover.

Posted in living room area contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources, personal policies, and abuse reporting procedures.

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

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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