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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592693
Report Date: 05/09/2023
Date Signed: 05/09/2023 05:30:55 PM

Document Has Been Signed on 05/09/2023 05:30 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:UNITED CARE HOMESFACILITY NUMBER:
191592693
ADMINISTRATOR:JOCELYN TUBIANOSAFACILITY TYPE:
735
ADDRESS:702 LYONWOOD STREETTELEPHONE:
(909) 869-7754
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 6CENSUS: 6DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Tita Baluyut, CaregiverTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Staff, Tita Baluyut. The purpose of the visit was explained. Administrator, Jocelyn Manalo, was informed of the inspection via telephone. The facility is licensed for (6) developmentally disabled clients, ages 18 - 59, of which 2 may be non-ambulatory in rooms #1 and #4. There are currently 6 clients residing at the home and were placed by the San Gabriel/Pomona Regional Center.

LPA toured the facility and observed the following:

The one-story home has 5 bedrooms (4 for clients and 1 for staff), 2 bathrooms, living room, kitchen, and an attached garage. Each client bedroom has the required furniture and lighting. There is a shaded area in the backyard for client use. There are no items obstructing the walkways. The facility does not have any swimming pool or bodies of water on the premises. The smoke detectors are located in each bedroom and a carbon monoxide detector in the hallway and are operable. Knives are locked in the kitchen cabinet. Cleaning solutions are located in a cabinet inside the garage. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. Staff are continuing to use appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once a day. There are sufficient food supplies of 2 day perishable and a week of non-perishable items observed. Foods are properly stored in the refrigerator to avoid contamination. LPA reviewed 6 client files today. The files were complete with the required documents. Per administrator, the clients' IPP meetings were held last week and have not obtained the copies from the regional center. There are no clients at the home with any restricted health conditions. The facility has an emergency and disaster plan posted. LPA informed the administrator about the different emergency scenarios drills that shall be conducted at least quarterly for each shift.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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: UNITED CARE HOMES
FACILITY NUMBER: 191592693
VISIT DATE: 05/09/2023
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LPA did not review staff files as they were not at the facility to inspect today, therefore, LPA could not determine if the staff files have the documents and training as required.

A deficiency was issued today. LPA also provided a technical assistance as indicated on the LIC9102 form.
An exit interview was held. A copy of this report and appeal rights were given to the staff.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2023 05:30 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 05/09/2023 at 01:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: UNITED CARE HOMES
FACILITY NUMBER: 191592693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
80066 Personnel records
(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above in which staff records were not avaible at the faciltity for LPA to review which poses a potential health and safety risk to persons in care.
POC Due Date: 05/16/2023
Plan of Correction
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The licensee shall ensure all personnel records are maintained on site and available for Licensing to review upon request. The POC shall be due on 5/16/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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