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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593069
Report Date: 04/25/2024
Date Signed: 04/25/2024 12:07:38 PM

Document Has Been Signed on 04/25/2024 12:07 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/
DIRECTOR:
HIGGINS, DELLAFACILITY TYPE:
735
ADDRESS:1105 OXFORD PLACETELEPHONE:
(909) 623-0555
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 2DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Della Higgins, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 4/25/24. LPA met with Administrator Della Higgins and explained the purpose for the visit. The facility is licensed for (4) adults ages 18-59, of which (2) may be non-ambulatory in bedroom #1. There are currently 2 clients residing at the home and receiving services by the San Gabriel/Pomona Regional Center.

LPA toured and inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool.

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. The facility has sufficient 2-day perishable and at least a week of non-perishable food. The foods in the refrigerator are properly covered to avoid contamination. LPA reviewed both staff files. Administrator (Della Higgins) certificate expires on 06/08/2024 and her HIV & TB training certificate was issued on 4/28/23. Staff have current CPR/first aid training and training hours that meet the annual requirement. LPA reviewed both client files and they have the required documentation including current Individual Program Plan. There are no clients with a restricted health condition and both are ambulatory. Medications are centrally stored and locked. Both clients are given their medications as prescribed. The facility has the Emergency Disaster Plan and are reviewed annually. Emergency drills are conducted every quarter.

No deficiencies were observed. Exit interview was held and a copy of this report was given to Mrs. Higgins.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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