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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802312
Report Date: 10/10/2022
Date Signed: 10/10/2022 02:18:51 PM

Document Has Been Signed on 10/10/2022 02:18 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:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Persiveranda DeVera (Administrator)TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Persiveranda DeVera (Administrator) and explained the purpose of the visit. The facility is licensed to serve: AMBULATORY ONLY, LICENSEE PREFERS TO SERVE MENTALLY DISABLED ADULTS AGES 18-59 YEARS.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, dining room, kitchen, 3 client bedrooms, 2 staff bedrooms, 2 bathrooms and an attached garage/laundry.

LPA observed the following during today's visit: The bathrooms are clean and operational. Clients bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested in the client bathroom and measured within Title 22 Regulation guidelines. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen and was fully charged. The first-aid kit is fully stocked with First-aid Manual. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. All staff have a criminal record clearance. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. Hygiene products are readily available. There are no pools or large bodies of water on the premises. All medications for residents are kept locked and inaccessible to other residents.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to the Persiveranda DeVera.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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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