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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802895
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:20:42 AM

Document Has Been Signed on 08/22/2022 11:20 AM - 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:ROSEMEAD HOMEFACILITY NUMBER:
197802895
ADMINISTRATOR:GUI-QIN ZONGFACILITY TYPE:
735
ADDRESS:3132 ROSEMEAD PLACETELEPHONE:
(626) 288-9346
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 6CENSUS: 3DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Guoliang Li, licenseeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the infection control domain. LPA arrived unannounced and met with the licensee, Guoliang Li. The purpose of the visit was explained. The facility is licensed to serve 6 Developmentally Disabled adults, ages 18 to 59, of which 3 may be non-ambulatory. The facility is vendorized by the Eastern Los Angeles Regional Center.

LPA Chan toured the facility and observed the following:
* The facility consists of 3 client bedrooms, 1 live-in staff bedroom, 2 bathrooms, living room, kitchen, and an attached garage.
* There is currently an extra room available as a isolation if one becomes symptomatic for COVID-19.
* Staff were observed wearing face masks and clients as tolerated.
* Staff disinfect and clean at least once a day and more often for the high touched surfaces. Cleaning supplies are stored and locked under the kitchen cabinet. Knives are locked under the stove area.
* PPE supplies such as hand sanitizers, gloves, and masks are available.
* There are sufficient supplies of 2 day perishable and a week of non-perishable items.
* The fire alarm and carbon monoxide detectors were tested and operable.
* Medications are centrally stored and locked in the cabinet. LPA reviewed the medications for all 3 clients and are being administered as prescribed by the physician.
* Per the licensee, he has developed a backup plan to obtain more staffing if needed.

LPA issued technical assistance for the following items:
* Additional COVID-19 signage to be posted at main door and throughout the home.
* Facility is to properly screen all individuals - clients, staff, and visitors and document on a log.

LPA did not issue deficiencies but rather technical advisories today. An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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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