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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593069
Report Date: 03/23/2023
Date Signed: 03/23/2023 04:28:14 PM

Document Has Been Signed on 03/23/2023 04:28 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:DELLA HIGGINS HOMEFACILITY NUMBER:
191593069
ADMINISTRATOR:HIGGINS, DELLAFACILITY TYPE:
735
ADDRESS:1105 OXFORD PLACETELEPHONE:
(909) 623-0555
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 2DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Della Higgins, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an annual inspection using the CARE tools. LPA arrived unannounced and met with Administrator Della Higgins. The purpose of the visit was explained. The facility is licensed for (4) adults ages 18-59 and (2) may be non-ambulatory in bedroom #1.

LPA toured the facility and conducted the following domains:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are still cleaning and disinfecting at least once a day. Facility has sufficient PPE supplies.

Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 2 client bedrooms, 2 Staff rooms, 2 bathrooms, living room, dining room, kitchen, enclosed patio, and detached garage. Each client bedroom has the required furniture and bedding. Extra hygiene supplies were observed. Facility has smoke and carbon monoxide combo detectors in each room. Knives, cleaning solutions, and disinfectants are locked. There are no firearms or weapons stored at the facility. The hot water temperature in the bathroom was measured between the required range of 105-120 degrees F.

Food Service: The facility has sufficient 2-day perishable and at least a week of non-perishable food supplies stored. The foods in the refrigerator are properly covered to avoid contamination.

LPA will return to complete the remainder of the domains on a later date. An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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