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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800633
Report Date: 03/29/2024
Date Signed: 03/29/2024 05:47:47 PM


Document Has Been Signed on 03/29/2024 05:47 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: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:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Back-Administrator Omar SapalaranTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit. LPA met with back-up Administrator Omar Sapalaran and explained the purpose of the visit. The facility is licensed to serve four (4) developmentally disabled non-ambulatory clients, ages 18-59. Clients receive case management services provided from San Gabriel/Pomona Regional Center. Facility annual fees are current. The facility is a single-story home located in a residential neighborhood consisted of four (4) client bedrooms, two (2) bathrooms, living room, dining room, kitchen, laundry area at the backyard, garage for storage and an outdoor activity area.
Front Yard: LPA Ramirez observed front yard to be free of hazards.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to one (1) out of four (4) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants to be inaccessible to one (1) out of four (4) clients in care.

Dining Room/Living room: Dining room was observed to contain one table with six (6) chairs. The living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed one (1) client sitting in this area during inspection.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. Bedroom#4 is currently unoccupied. LPA Ramirez observed an operational manual mechanical lift in bedroom#1.

Bathroom 1-2: Water temperature in two (2) client bathrooms were within 105- 120 degrees F. Bathrooms were observed to be clean and well stocked. Grab bars were observed in bathroom A.

Backyard: No large bodies of water were observed.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit. Fully charged fire extinguishers were observed throughout the facility. SEE 809-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: JOMAR RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197800633
VISIT DATE: 03/29/2024
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Due to time constraints, LPA Ramirez will return at a later time to complete annual inspection.

No deficiencies were observed during inspection. Exit interview was conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2