<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502342
Report Date: 07/23/2020
Date Signed: 07/24/2020 10:38:42 AM

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:WESTERN ASSEMBLIES HOMEFACILITY NUMBER:
191502342
ADMINISTRATOR:LYNN HUGHESFACILITY TYPE:
740
ADDRESS:350 BERKELEY AVENUETELEPHONE:
(909) 626-3711
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:36CENSUS: DATE:
07/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Executive Director, Rod ChanceTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Regional Managers (RM) Araceli Ramirez and Benita Yates made an unannounced visit to the facility above for the purpose of conducting a Case Management visit. Licensing Program Analyst (LPA) Linda Almaraz joined the visit virtually. During today's visit RM's and LPA met with Executive Director, Rod Chance and explained the reason for the visit.

During today's visit RM Ramirez and Yates toured the inside and outside physical plan of the facility. RM's observed walk ways free from obstruction. Facility appears clean and odor free. The facility has ample amount of PPE and cleaning supply. Hand Sanitizer were observed through the facility. COVID- 19 signs present in the hallways, restrooms, and positive COVID-19 rooms. Call light system for residents working properly. The facility maintains an adequate amount of food supply. Resident in Room#5 and Room #D appeared well groomed and content.

The following documentation was requested: List of questions asked to visitors before entry, last fire inspection and most recent Staff roster and schedule.
The following were missing and will be obtained and present at the First Aid Kit and lids for Trash Cans.

Exit interview was conducted with Executive Director and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1