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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803031
Report Date: 02/17/2023
Date Signed: 02/17/2023 05:01:57 PM

Document Has Been Signed on 02/17/2023 05:01 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:TRI-STAR HOMESFACILITY NUMBER:
197803031
ADMINISTRATOR:DARWIN BELMONTEFACILITY TYPE:
735
ADDRESS:2266 RALEO AVENUETELEPHONE:
(626) 269-0241
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 4DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Darwin Belmonte TIME COMPLETED:
01:50 PM
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Licensing Program Analysts (LPAs) Christine Wong and Tena Herrera conducted an unannounced annual required visit. LPA's met with caregiver Celia Belmonte and explained the reason for the visit. Shortly after, the administrator Darwin Belmonte arrived and assisted with the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, three clients bedrooms, one client bathroom, one live in staff bedroom, dining area, kitchen and an attached garage which the laundry room is in the garage. All 3 clients bedrooms were toured. Each bedroom has two beds, drawers, required bed linen and furniture and sufficient closet space and lighting. The client bathroom is clean, sanitary and in a good working condition. The hot water temperature in the client bathroom were tested at 120 degrees F. The refrigerator in the kitchen and cabinet in the garage has sufficient 2 days perishable and 7 days non-perishable food supply. All the appliances in the kitchen are clean and working properly. All the sharp knives and utensils are locked in the cabinet in the garage and inaccessible for the clients. All the chemicals are locked in the garage and its inaccessible for the clients. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well. The back yard has a shaded area with chairs and table for client to utilize.

LPAs reviewed all 4 clients files to confirm emergency contact is updated. LPAs reviewed 2 staff files and they all have fingerprint cleared and updated health screening on the personnel files. LPA also inspected 3 client medication and they are centrally stored and locked in the medication cart and all medication seemed accurate and up-to-dated.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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: TRI-STAR HOMES
FACILITY NUMBER: 197803031
VISIT DATE: 02/17/2023
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility. Facility is disinfected every day. Client's bathroom and the garage have sufficient soap, paper towels, and signs. Facility has sufficient PPE supplies for more than 30 days.

No deficiencies were observed during the visit.

Exit Interview Conducted and a copy of the report was provided to the administrator Darwin Belmonte.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC809 (FAS) - (06/04)
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