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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800633
Report Date: 05/25/2022
Date Signed: 05/25/2022 04:50:43 PM

Document Has Been Signed on 05/25/2022 04:50 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JOMAR RESIDENTIAL CARE CENTERFACILITY NUMBER:
197800633
ADMINISTRATOR:JOSEPHINE SAPALARANFACILITY TYPE:
735
ADDRESS:3920 N FRIJO AVETELEPHONE:
(626) 338-4551
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 4DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Josephine Sapalaran, Administrator
Lerma Castardo, Staff
TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Lerma Castardo. LPA spoke with Omar Sapalaran, administrator assistant over the phone during the visit. Josephine, administrator, joined the visit at the exit interview. The facility is licensed to serve six (6) developmentally disabled non-ambulatory clients, ages 18-59. No clients with restricted health conditions. Facility annual fees are current. LPA explained the purpose of today's visit and the inspection to the administrator assistant and staff.

During the visit, the inspection consisted of using infection control domain, conducting a tour of the facility; reviewing food supply; and reviewing client's medications.

The facility is a single-story home located in a residential neighborhood consist of three (3) client bedrooms, one (1) storage room, two (2) bathrooms, a living room, a dining room, kitchen, laundry area at the backyard, garage for storage and an outdoor activity area. The yard has a shaded area and free of debris/ hazard. Bathrooms are clean and operable. Sharp items and toxic supplies are locked and inaccessible to clients. Sufficient supply of perishable and non-perishable foods are observed. Adequate linen and personal hygiene supply are in stock. Smoke detectors and carbon monoxide devices are dual, hardwired and operable. Hot water temperature measured at 116.8 degrees Fahrenheit. The last Fire/ Emergency Drill was conducted on 12/4/21. Fire extinguisher is fully charged. Medications are centrally stored, locked and the records are current. Hazardous items are locked and inaccessible to clients. Administrator certificate is current with expiration date on 04/01/2023.

No deficiencies are cited per CCR, Title 22. Exit conference was conducted with administrator. LIC 809 was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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