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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222591
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:55:18 PM

Document Has Been Signed on 07/11/2024 01:55 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOMES FOR LIFE FOUNDATION-MADISON HOUSEFACILITY NUMBER:
191222591
ADMINISTRATOR/
DIRECTOR:
CAROL LIESSFACILITY TYPE:
735
ADDRESS:489 N. MADISON AVENUETELEPHONE:
(626) 583-8019
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 9CENSUS: 8DATE:
07/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:26 PM
MET WITH:Imelda Jonson - Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility to follow up on deficiencies noted on 5/30/24 during an annual inspection visit. LPA met with Imelda Jonson and explained the reason for the visit.

On 5/30/24 LPA Flores conducted an unannounced annual visit at the facility and noted the following deficiencies:

Type A - Section 80088(e)(1) - Fixtures, Furniture, Equipment, and Supplies: On 5/30/24 LPA Flores measured bathroom #1 water temperature at 122.2 degrees F. On 7/11/24 LPA tested water temperature in bathroom #1 and measured at 119.4 degrees F., which is within the required temperature of 105-120 degrees F. Deficiency cleared as of 7/11/24.

Type B - Section HSC 1565(d) Other Provisions: On 5/30/24 LPA reviewed Emergency Disaster Plan LIC 610(10/03) which does not meet the requirements of LIC 610(12/21). On 6/6/24 a copy of LIC 610 (12/21) was email to LPA. Deficiency cleared as of 6/6/24.

Exit interview was conducted with Imelda Jonson and a copy of this report, and clearance letters were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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