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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592693
Report Date: 05/23/2024
Date Signed: 05/23/2024 12:05:45 PM

Document Has Been Signed on 05/23/2024 12:05 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/
DIRECTOR:		JOCELYN TUBIANOSAFACILITY TYPE:
735
ADDRESS:702 LYONWOOD STREETTELEPHONE:
(909) 869-7754
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 6CENSUS: 6DATE:
05/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Luisa Larioza, StaffTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA met with staff, Luisa Larioza, and explained the reason for the visit. The initial visit began on 5/16/24.

LPA completed the remainder of the inspection using the CARE tool. The following were observed:
Staffing: There are sufficient staffing to assist the current 6 clients with their needs and provide supervision at all times. Personnel Records - Training: The staff are all fingerprint cleared and associated to the facility. LPA reviewed records for 3 staff and they have the required documents in their files - health screening form, TB test result, Personnel record, CPR training certificate, and training log. Client Rights - Information: The facility provides internet access and clients have devices to use. There are no clients who are using postural supports at this time. Client Records - Incident Reports: LPA reviewed all 6 client files today. Each of the files has the required documents such as the admission agreement, medical assessment including TB results, current IPP reports, consent forms, and property valuable forms. Health-Related Services: Medications are centrally locked and inaccessible to clients. LPA reviewed medications for 6 clients. There were no discrepancies found. Incidental Medical Services: There are no clients with restricted or prohibited health conditions residing at the home. Disaster Preparedness: The facility has an emergency disaster plan. The plan has at least 2 shelter locations and instructions to shutoff utility valves. The facility is currently conducting quarterly drills. Emergency Intervention: The facility staff do not utilize any manual restraints on clients.

There are no deficiencies observed today. An exit interview was held and a copy of this report was given to staff Luisa.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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