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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802483
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:25:03 PM

Document Has Been Signed on 02/29/2024 01:25 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:STEWART RESIDENTIAL HOMEFACILITY NUMBER:
197802483
ADMINISTRATOR:STEWART, MILLIEFACILITY TYPE:
735
ADDRESS:1591 SHIRLEY PLACETELEPHONE:
(909) 868-6524
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Millie Stewart/S-1TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Millie Stewart. LPA discussed the purpose of today's visit.

The facility is licensed for (4) ambulatory clients ages 18 through 59. The fire clearance is approved for (4) ambulatory clients. All clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an infection control plan in place.

Operational Requirements: The fire clearance is approved for (4) ambulatory clients. Last Fire Drill and Earthquake Drill were conducted on 09/30/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: This facility consists of (3) bedrooms (1) bathroom, living room, den/tv room, kitchen, dining area, laundry area and attached garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full and was last serviced on 01/23/24. Carbon monoxide tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Millie Stewart expires on 07/07/25. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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: STEWART RESIDENTIAL HOME
FACILITY NUMBER: 197802483
VISIT DATE: 02/29/2024
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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1/Facility Administrator through S-4. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Client Rights-Information: Client personal rights are posted and filed in client files.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-3. Client files are maintained at the facility. Admission Agreement, Functional Capability Assessment, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Appraisal/Needs and Services Plan, Behavioral Reports, Weight Record, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: Food supplies of 2-day perishable and a week of non-perishable items observed. The food is properly stored in the refrigerator. Per Administrator, there are no clients on modified diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services The medications are bubbled packed, centrally stored and locked. Medications are administered as prescribed by the Physician. Staff utilize the Medication Administration Record (MAR) log to document administered medication.

Incidental Medical Services: Per Administrator, there are no clients at this home with postural supports nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan (LIC 610D-9 pages).

Exit interview, appeals rights and a copy of this report was provided to Millie Stewart.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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