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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592149
Report Date: 08/09/2022
Date Signed: 08/09/2022 10:59:08 AM

Document Has Been Signed on 08/09/2022 10:59 AM - 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:LOVING CARE GUEST HOMEFACILITY NUMBER:
191592149
ADMINISTRATOR:SABIO, MARILYNFACILITY TYPE:
735
ADDRESS:15027 - 15031 BLACKWOOD STTELEPHONE:
(626) 917-2312
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 12CENSUS: 11DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Aiona Fortaleza TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with caregiver Cynthia Remogat and explained the reason for the visit. Shortly After, the assistant manager Aiona Fortaleza arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed the food supply, staff and clients files and clients' medication.

The facility contains 2 Buildings. In Building 15027 there are 4 Client Bedrooms and 1 Staff Room and 1 client bathrooms. Building 15031 there are 3 Client Bedrooms and 1 Staff Room and 1 client bathroom and 1 staff bathroom, living room, kitchen, dining area and the porch. Each client bedroom is no more than two clients per bedroom and they are all equipped with the proper furniture and linen; All the bathrooms are clean and operational.. LPA tested the two clients' bathroom hot water temperature in the front house and back house are between 111.4 and 117.1 degrees F which is within the Title 22 regulation. All the appliances are clean and working properly. The common areas such as living room and dining are are clean and have the required furniture. One week supply of non perishables and 2 days perishable food were sufficient. LPA also tested the smoke detectors and carbon monoxides in the front house and back house and they are all interconnected and operable. All outdoor and indoor passageways were free of obstruction.
LPA reviewed clients files and all their emergency contact information are updated. LPA also inspected two staff files for their health screening and fingerprint cleared. Both staff files have updated health screening in their personnel files and they are both fingerprint cleared. LPA inspected four clients medication and all the medication are centrally stored in the kitchen cabinet and they are seemed accurate and updated.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing, disinfecting products are available in each room and facility is disinfected every 2 hours, bathrooms have sufficient soap, paper towels, and signs, facility has an isolation room and a cart with PPE supplies, and PPE supplies are stored for more than 30 days.

No deficiencies observed during the visit. A copy of the report will be provided to assistant manager.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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