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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800633
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:25:35 PM

Document Has Been Signed on 06/23/2023 04:25 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: 4CENSUS: 4DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Omar Sapalaran, assisted administratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Omar Sapalaran, assisted administrator who assisted with the visit. The facility is licensed to serve four (4) developmentally disabled non-ambulatory clients, ages 18-59. Clients received case management services provided from San Gabriel Pomona regional center. No clients have restricted health conditions. Facility annual fees are current. LPA explained the purpose of today's visit.

During the visit, the inspection consisted of using CARE tool, conducting facility tour; reviewing food supply; reviewing staff/clients files; interviewing staff/clients, and reviewing client's medications.

The facility is a single-story home located in a residential neighborhood consisted of four (4) client bedrooms, one (1) storage room, two (2) bathrooms, living room, 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. 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 110.5 degrees Fahrenheit. Fire extinguisher is fully charged. Medications are centrally stored, locked and the records are current. Hazardous items are locked and inaccessible to clients.

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

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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