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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800979
Report Date: 12/19/2022
Date Signed: 02/03/2023 01:56:03 PM


Document Has Been Signed on 02/03/2023 01:56 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:ELMWOOD PARKFACILITY NUMBER:
197800979
ADMINISTRATOR:JONES, TAMARA LYNNFACILITY TYPE:
735
ADDRESS:259 FREDATELEPHONE:
(909) 625-3345
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:6CENSUS: 3DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Tamara JonesTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Tamara Jones and discussed the purpose of today's visit.

This home consists of (3) client bedrooms, (2) bathrooms, living room, kitchen, dinning area, laundry room is next to the kitchen and attached garage. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE observed. Additional supplies are stored inside the garage.
  • Hygiene supplies observed. Additional supplies are stored inside the garage.
  • Bathrooms have hand soap, paper towels and hand washing signs.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional non-perishable food supply stored inside the garage.
  • Per Administrator, C-1 through C-3 are vaccinated and have (1) booster.
  • Per Administrator, staff are vaccinated and have (2) boosters.
  • Medication reviewed for Client #1 through Client #3 (C-1 through C-3).
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Tamara Jones
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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