197801689-5-9-2024-28-AS-CWOG-D54VHC-20240509162656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801689
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:27:34 PM

Document Has Been Signed on 05/09/2024 04:27 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:	FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED		FACILITY NUMBER:	197801689
ADMINISTRATOR/ DIRECTOR:	TAMARU FRANCIS		FACILITY TYPE:	735
ADDRESS:	715 E. CHESTER ROAD		TELEPHONE:	(626) 858-1803
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY: 6		CENSUS: 6	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Tamaru (Nikki) Francis		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with the Licensee Valarie Donelson and administrator Tamaru (Nikki) Francis and allowed the entry of the visit and assisted with today's visit. The purpose for the visit was explained. The facility is licensed and APPROVED FOR 6 AMBULATORY CLIENTS, AGES 18-59 and the facility is vendored as Level 4F with San Gabriel Pomona Regional Center. 1. Infection Control: The facility has an Infection Control Plan in place and the facility continue to practice infection control with hand washing and disinfecting the facility. The facility has sufficient PPE supplies. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: kitchen, dining area, living room, three clients bedrooms, two clients bathrooms and a detached garage. Each client's bedroom has two beds, two drawers, night stand, required furniture and beddings and sufficient lighting and close space. The client's bathrooms are clean, sanitary and in a good working condition. The hot water temperature in both bathrooms were tested between 113.7 and 116.2 degrees F which is within the Title 22 regulation. All the kitchen appliances are working properly. All the sharp knives and utensils are stored and locked in the kitchen cabinet. All the chemical and cleaning supplies are stored and locked in the cabinet near the entrance way. The extra personal hygiene are stored in the cabinet near the entrance way. There's a telephone service on the premises. The Hallway Light and automatic light will be on during night time for client to access the non-private bathrooms. LPA inspected the carbon monoxide detectors and it's working well. The passageway, walkway and patio are free of obstruction.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED	FACILITY NUMBER: 197801689
	VISIT DATE: 05/09/2024

NARRATIVE

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3. Operational Requirement: The facility is approved for 6 ambulatory clients and currently all clients are ambulatory which is within the fire clearance requirement. The clients can participate the community events if there's an opportunity. There is table and chairs in the covered patio area for client to utilize the outdoor activity. The last fire drill was conducted on 4/15/24

4. Staffing: The facility has sufficient staffing. The night staff has the required emergency planned procedure training.

5. Personnel Record: All staff files are stored and locked in the staff office. All the facility staff are over 18 years old, fingerprint cleared and associated with the facility. All the staff files have the required documents included: health screening, TB test result, required training hours and updated first aid certificate. The administrator is Tamaru Francis and her administrator certificate is expired on 5/30/2024 and she has the updated HIV and TB training certificate.

6. Client's right information: Currently no clients required any postural support. The facility has served internet services with at least one internet access device , so clients can communicate with their family or day program or physician.

7. Food Service. The facility has 2 days perishable and 7 days non-perishable food supply in the facility. All the food are stored properly in the facility. Currently no client is on any special diet.

8. Client's Records-Incident Reports. All the client's files are stored and locked in the staff office. All the client's files have the required documents included: face sheet, physician report wtih TB test result, admission agreement, functional capacity assessment, Individual program Plan (IPP), ambulatory status and medication list.

9. Health Related Services: The facility will assist client with their medical and dental appointments with transportation too. LPA reviewed all six (6) client's medication and all medication are centrally stored in the kitchen cabinet and they all seemed updated and accurate and they all have 30 days supply for medication.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED	FACILITY NUMBER: 197801689
	VISIT DATE: 05/09/2024

NARRATIVE

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10. Incidental Medical Services: No client in the facility has any restricted health condition or prohibited health condition.

11. Disaster Plan: The facility has an updated emergency disaster plan. The facility has two alternatived shelter location in place. The facility usually conduct a fire/disaster drill every month and every six months for the detailed one.

12. Emergency Intervention. The facility does not use any restraints but all staff are Pro Act trained with an updated certificate.

No deficiencies were observed during the visit.

An exit interview conducted and a copy of the report was provided to administrator Tamaru Francis

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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