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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222591
Report Date: 06/15/2022
Date Signed: 06/15/2022 02:40:33 PM

Document Has Been Signed on 06/15/2022 02:40 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:HOMES FOR LIFE FOUNDATION-MADISON HOUSEFACILITY NUMBER:
191222591
ADMINISTRATOR:CAROL LIESSFACILITY TYPE:
735
ADDRESS:489 N. MADISON AVENUETELEPHONE:
(626) 583-8019
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 9CENSUS: 8DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lourdes Balolong - House Manager
Katrin Silvestro - Facility's Social Worker
TIME COMPLETED:
03:00 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food and medication review. LPA met with Lourdes Balolong House Manager and Katrin Silvestro Facility's Social Worker and explained the reason for the visit.

Facility is a two story home licensed to serve 9 adults between the ages of 18 to 59 years old, ambulatory only. Facility's outside is in good condition, no large bodies of water observed and has a front porch or backyard. Facility has 5 client bedrooms, 2 client bathrooms, 1 staff bedroom with a private staff bathroom, a kitchen, laundry, living room and dinning/office room and a detached garage.

LPA toured the facility with Lourdes Balolong House Manager and Katrin Silvestro Social Worker observed the following:
Kitchen: LPA observed sufficient food for 8 clients for at least 2 days of perishables and 7 days of non-perishables. Sharp objects, and cleaning/ disinfecting supplies were under lock under sink. Medications were observed locked in dining room. Living room allows social distance for clients. LPA observed room #1#2,#3,#4,#5. Clients rooms had all sufficient lighting, and required furniture and bedding. bathroom #1(B1) and #2(B2) had hand soap, no paper towels were observed, hand washing signs, grab bars, and skit mats in shower; water temperature was tested in B1 at 105.4 degrees F, and B2 tested at 104.3 degrees which is not within the required range of 105 to 120 degrees F. LPA observed PPE supplies for at least 30 days in garage and additional food supplies. LPA reviewed files and medication for client #1(C1),#2(C2),#3(C3), and staff #1 file. Fire extinguishers were last updated on Sept 2021. Smoke/Carbon dioxide detectors were tested and in working condition. Administrator certificate was observed for Carol M. Liess #6025209735 exp: 2/25/23.
Facility is following infection control guidance except screening should be by entry point and hand sanitizer should be available in the entrance.
Technical Advisories(TA) and violation(TV) were given during this visit. Exit interview was conducted with Katrin Silvestro Facility's Social Worker and a copy of this report, technical advisories and violation was given.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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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