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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802942
Report Date: 01/27/2024
Date Signed: 01/27/2024 01:58:59 PM

Document Has Been Signed on 01/27/2024 01:58 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:CITRUS RESIDENTIAL FACILITYFACILITY NUMBER:
197802942
ADMINISTRATOR:VILORIA, MANUELITAFACILITY TYPE:
735
ADDRESS:1329 N. CITRUS AVENUETELEPHONE:
(626) 966-6063
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 6DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administraor Manuelita ViloriaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 12/21/2023. LPA Ramirez was met by Licensee/Administrator Manuelita Reyes and explained the purpose of the visit. The facility is approved for six (6) ambulatory developmentally disabled adults, ages 18-59.

LPA OBSERVATIONS: The facility is a single-story dwelling located on a main street. The facility consists of three (3) client bedrooms, three (3) staff bedrooms, two (2) full bathrooms, kitchen, dining room, living room, front yard, backyard and attached garage.

Front Yard: LPA Ramirez observed front yard to be free of hazards. Front yard was well maintained.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed a fully charger fire extinguisher nearby. Kitchen sink temperature was measured at 103.6-degree F. Knives and sharps were observed in locked safe on top of kitchen counter.

Dining Room/Living room: Dining room was observed to contain one table with five (5) chairs. Living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed nearby thermostat to read 69 degrees F.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 3: LPA Ramirez observed client bedrooms#1-3 to contain the required linens, furnishings, and lighting. All client bedrooms are currently shared.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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: CITRUS RESIDENTIAL FACILITY
FACILITY NUMBER: 197802942
VISIT DATE: 01/27/2024
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Bathroom 1-2: LPA Ramirez observed nonslip mats in bathrooms showers. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. Water temperature in bathroom#1 was measured at 105.8 degree F. Bathroom#2 was in use while LPA toured facility.

Backyard: No large bodies of water were observed. Pool was observed to be drained of water and observed to have a net over pool. Pool area was observed to contain a locked gate around pool.

Emergency Drills: Last documented disaster drills (earthquake and fire) were conducted on 12/2/23 at 2:00pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed four (4) personnel records. LPA Ramirez observed Administrator’s certificate for Roberto Reyes with an expiration date of 06/12/2024 and an expired Administrator’s Certificate for Manuelita Reyes with an expiration date 07/28/2023. LPA Ramirez verified Manuelita Reyes’s administrator’s certificate is pending processing.

Client Files: Client files were maintained at facility. LPA Ramirez reviewed six (6) client files.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

No deficiencies were issued today. Exit interview was conducted. A copy of this report and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC809 (FAS) - (06/04)
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