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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802483
Report Date: 03/15/2022
Date Signed: 03/15/2022 02:11:19 PM

Document Has Been Signed on 03/15/2022 02:11 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:STEWART RESIDENTIAL HOMEFACILITY NUMBER:
197802483
ADMINISTRATOR:STEWART, MILLIEFACILITY TYPE:
735
ADDRESS:1591 SHIRLEY PLACETELEPHONE:
(909) 868-6524
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:S-1/Facility AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1/Facility Administrator and explained the purpose of today's visit.

This home consists of (2) private client bedrooms, (1) shared bedroom, (1) bathroom, living room, den/T.V. room, kitchen, dinning area, laundry room and attached garage. LPA toured grounds. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE and hygiene supplies observed. These items are stored inside the garage.
  • Bathroom has hand soap and hand sanitizer.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supply observed inside the garage.
  • Per Administrator, all (4) clients are fully vaccinated including booster.
  • Medication reviewed for (4) Clients (Client #1 through Client #4).
  • Per Administrator, all staff are fully vaccinated including booster.
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1/Facility Administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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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