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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801816
Report Date: 12/27/2022
Date Signed: 12/27/2022 02:41:12 PM

Document Has Been Signed on 12/27/2022 02:41 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:MSJI HOME INCFACILITY NUMBER:
197801816
ADMINISTRATOR:INDIRA BHAVSARFACILITY TYPE:
735
ADDRESS:1324 JUANITA AVETELEPHONE:
(909) 592-6003
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 4DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Rhodora Cabrera, StaffTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control Domain. LPA Chan arrived unannounced and met with Staff, Rhodora Cabrera and explained the purpose of the visit. The Administrator, Indira Bhavsar, arrived shortly thereafter. The facility is licensed for 6 Developmentally Disabled adults ages 18 through 59, and only one may be non-ambulatory. There are currently 4 clients residing at the facility.

The inspection consisted of the following:
  • The facility consists of 3 client bedrooms, 2 bathrooms, living room, dining room, kitchen, and an attached garage which is used as the administrator's office.
  • COVID-19 signage are posted at the front door and throughout the home including bathrooms.
  • Screening and temperature are taken for clients, staff, and visitors upon entry.
  • PPE supplies for at least 30-days such as N95 masks, gowns, and gloves are observed.
  • Cleaning solutions and disinfectant sprays are locked in the laundry area.
  • Sufficient food supplies of 2-day perishable and a week of non-perishable are maintained at the facility.
  • Medications are locked and centrally stored in the medication cabinet. LPA reviewed the medications for all 4 clients and they are being administered as prescribed and properly documented.
  • Fire extinguishers were observed to be fully charged and last inspected on 1/21/22.
  • Clients' emergency contact information are up-to-date.
  • Staff are cleaning and disinfecting on every shift and documented. Professional cleaner comes every month to disinfect the entire house.
  • Per the Administrator, they are still following the strictest guidance and providing staff with most current COVID-19 updates.
No deficiencies observed during the visit today. An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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