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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800835
Report Date: 12/09/2022
Date Signed: 12/09/2022 04:42:06 PM

Document Has Been Signed on 12/09/2022 04:42 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:HEGLIS CARE HOMEFACILITY NUMBER:
197800835
ADMINISTRATOR:JANE ANNE CUAFACILITY TYPE:
735
ADDRESS:3218 HEGLIS AVE.TELEPHONE:
(626) 280-0061
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 3DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria Romero, StaffTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the infection control domain. LPA met with staff, Maria Romero, and explained the purpose of the visit.
The facility prefers to serve developmentally disabled adults, 18-59 years old, and which 2 may be ambulatory and 2 non-ambulatory. There are current 3 clients residing in the home and are placed by the Eastern Los Angeles Regional Center.

LPA Chan toured the facility and observed the following:
* There are 4 bedrooms, one Administrator's office, 2 bathrooms, living room, dining area, kitchen, and a detached garage. Each client has his/her own room. There are no obstructions to the passageways and no bodies of water.
* The facility has proper Coronavirus (COVID-19) signage around the home in both English and Spanish. Hand washing signs are posted in each of the bathrooms and sink.
* Staff takes the temperature of all visitors and clients returning from day program. LPA advised staff to include the COVID-19 questionnaire as part of their screening protocol.
* The facility keeps a sign-in log and PPE supplies by the front door.
* The client bedrooms are equipped with the required furniture.
* Food supplies for 2 day perishable and a week of non-perishable were observed.
* Knives and sharps are stored and locked making them inaccessible to clients.
* Cleaning supplies are stored and locked above the washing machine.
* Medications are centrally stored and locked in the kitchen cabinet. LPA reviewed 2 clients' medications and they are being administered as prescribed. The other client does not take daily medication.
* All staff on duty were wearing face masks.
* Staff are cleaning/disinfecting before and after each shift.

No deficiencies issued today. Exit interview held and a copy of this report was provided to Maria Romero.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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