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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802312
Report Date: 10/20/2021
Date Signed: 10/20/2021 08:14:43 PM

Document Has Been Signed on 10/20/2021 08:14 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:HAYLAND GUEST HOMEFACILITY NUMBER:
197802312
ADMINISTRATOR:DE VERA, PERSIVERANDAFACILITY TYPE:
735
ADDRESS:16425 E. HAYLAND ST.TELEPHONE:
(626) 961-4039
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 6DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Persiveran De Vera-AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with the staff Ferdinand De Vera and administrator, Persiveran De Vera and explained the reason of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and is approved on 04/18/21.

The facility is a single story house located in residential neighborhood. The facility consists of three clients bedrooms, one client bathroom, one master bedroom with a bathroom for administrator, husband and son who live in the facility, living room, dining room, activity room/patio, kitchen and an attached garage. All clients' bedroom has two beds, two dressers, closet and adequate lighting. Facility has sufficient linen supply including mattress pads. The hot water temperature in the bathroom was measured at 116.1 degrees F which within the Title 22 regulation. The food supply both perishable and non-perishable is sufficient. The common areas such as living room and dining room are clean and have the required furniture. The back yard has a shaded area and sitting area. The smoke detectors and carbon monoxide detectors are inter-connected and it is operational.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing between clients, facility is disinfected two times per day, facility has sufficient PPE supplies and cleaning supplies/products.

No deficiencies were observed.

Exit Interview conducted. The copy of the report was provided to administrator Persiveran De Vera
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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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