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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800835
Report Date: 01/27/2022
Date Signed: 01/27/2022 04:06:06 PM

Document Has Been Signed on 01/27/2022 04:06 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:HEGLIS CARE HOMEFACILITY NUMBER:
197800835
ADMINISTRATOR:MILLET PINEDAFACILITY TYPE:
735
ADDRESS:3218 HEGLIS AVE.TELEPHONE:
(626) 280-0061
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 1DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Melissa Ruga, DSP TIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Melissa Ruga and explained the purpose of the visit. Administrator Jane Anne Cua was explained the purpose of the visit telephonically.There is one (1) level 4i developmentally disabled resident ages 18-59. The facility is serviced by Eastern Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood that is licensed for 2 non- ambulatory residents and 2 ambulatory residents. It consists of 4 bedrooms, 1 staff room, office, 2 1/2 bathrooms, living room, dining area, kitchen with laundry area, outdoor patio area, and a detached garage. The last fire drill was conducted on 1/14/2022. Administrator certificate expires 1/11/2023.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. Staff was observed wearing a surgical mask.
  • COVID-19 Infection Control screening and signs were observed in the entrance, common areas, hallways, and bathrooms. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Facility has an approved COVID-19 Mitigation Plan.
  • Each resident room has been designated as a COVID-19 solation room if needed.
  • One (1) centrally stored resident medication record was reviewed.
  • Residents in care do not wear masks because it is not tolerated due to cognitive impairment.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.
  • No health and safety issues were observed.


No deficiencies were cited.

Exit interview was conducted with staff Melissa Aruga. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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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