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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592503
Report Date: 08/29/2024
Date Signed: 08/29/2024 02:28:02 PM

Document Has Been Signed on 08/29/2024 02:28 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:CASA COLINA TRANSITIONAL LIVING CENTERFACILITY NUMBER:
191592503
ADMINISTRATOR/
DIRECTOR:		STEPHANIE KAPLANFACILITY TYPE:
735
ADDRESS:250 E. HARRISONTELEPHONE:
(909) 596-7733
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 49CENSUS: 49DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Rachel Tran and Linda LeyvaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Rachel Tran and discussed the purpose of today’s visit. Linda Leyva arrived at approximately 9:10 A.M..

LPA utilized the Compliance and Regulatory (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an Infection Control and Prevention Plan in place.

Operational Requirements: Staff are adhering to operational requirements. This facility has a fire clearance for (46) non-ambulatory clients and (3) bedridden clients.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detectors observed. Fire extinguishers were last serviced 08/06/24. Last fire drill was conducted on 08/22/24. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Hot water supply measured between 107* to 116*.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: LPA reviewed staff files for Staff #1 (S-1) through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis clearance.

Client Rights-Information: Client rights are posted and were also observed in client files.

**Refer to LIC 809C for the continuation of this report**
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: CASA COLINA TRANSITIONAL LIVING CENTER
FACILITY NUMBER: 191592503
VISIT DATE: 08/29/2024
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Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #5 (C-5). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent For Medical Treatment, Appraisal Needs and Services Plan, House Rules, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Emergency water supply observed. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Facility is adhering to incidental medical services.

Disaster Preparedness: The facility has an Emergency Disaster Plan in place. Last emergency drill was conducted on 08/03/24.

Exit interview, appeals rights and a copy of this report was provided to Rachel Tran.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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