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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801689
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:57:21 PM

Document Has Been Signed on 06/22/2022 04:57 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:FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLEDFACILITY NUMBER:
197801689
ADMINISTRATOR:TAMARU FRANCISFACILITY TYPE:
735
ADDRESS:715 E. CHESTER ROADTELEPHONE:
(626) 858-1803
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 6CENSUS: 6DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Tamaru Francis TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with Administrator Tamaru Francis and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients' and staff files. Facility has submitted a mitigation plan and was approved 4/25/2021.

The facility is a single story house and located in a residential neighborhood area. The facility consists of kitchen, dining area, living room, three clients bedrooms, two clients bathrooms, office/supply room and a detached garage. All clients bedrooms were toured. It included two beds, two dressers, required furniture and linen, sufficient lighting and closet space. The two clients bathrooms also toured and they are clean and sanitary and working condition. The hot water was measured between two bathrooms are 113.2 and 114.2 degrees F. The refrigerator and kitchen cabinet in the kitchen and three freezers in the garage have sufficient food supply for two days perishable and seven days non-perishable. The sharp knives and utensils are locked in the kitchen cabinet next to the refrigerator. All the appliances in the kitchen are clean and working properly. The common area such as living room and dining area are clean have the required furniture. The front and back yard are maintained well. The exit and passage way are free of obstruction. The back yard has tables and chairs with shaded area for clients to utilize. The smoke detectors and carbon monoxide detectors are interconnected and located in each bedroom and common area and they are all working well.

LPA reviewed 6 clients' files to confirm emergency contact is updated. LPA also reviewed two staff files to confirm health screenings and fingerprint clearances and they are all fingerprint cleared and their health screenings are updated on the staff files. LPA reviewed all 6 clients' medications and they all seemed accurate and updated.

(See LIC 809C for continuation)
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED
FACILITY NUMBER: 197801689
VISIT DATE: 06/22/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, facility is clean and disinfected two three times a day and sanitizing the whole facility once a month. The bathrooms also have sufficient soap, paper towels, and signs and PPE supplies are sufficient for more than 30 days.

No deficiencies were found during this visit. Exit interview was conducted with Administrator Tamaru Francis and a copy of this report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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