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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500097
Report Date: 08/12/2022
Date Signed: 08/12/2022 01:07:51 PM

Document Has Been Signed on 08/12/2022 01:07 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:BECKFORD WAY HOMEFACILITY NUMBER:
191500097
ADMINISTRATOR:NICOLAS, ROSARIO G.FACILITY TYPE:
735
ADDRESS:1224 BECKFORD WAYTELEPHONE:
(909) 621-2543
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 4DATE:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:S-1TIME COMPLETED:
01:15 PM
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 Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and explained the purpose of today's visit.

This single family home which consists (6) bedrooms, (2) bathrooms, living room, family room, kitchen, dinning area and an attached garage.


The following were observed/inspected: .
  • COVID-19 Infection Control Practices were observed.
  • COVID-19 signs were posted throughout this facility.
  • Bathrooms had hand soap, hand sanitizer and paper towels.
  • PPE and hygiene supplies observed.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. There is an additional refrigerator inside the garage. Additional water supply was also observed.
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.
  • Medication reviewed for (4) Clients (Client #1 through Client #4).
  • Per Administrator, (4) staff have both COVID vaccines and have the booster.
  • Per Administrator, (4) clients have both COVID vaccines and have the booster.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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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