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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803078
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:32:47 PM


Document Has Been Signed on 10/20/2022 02:32 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:SAN GABRIEL VALLEY TRAINING CENTERFACILITY NUMBER:
197803078
ADMINISTRATOR:HARMON, SUSANAFACILITY TYPE:
740
ADDRESS:339 S. COVINA BLVD.TELEPHONE:
(626) 369-3398
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY:12CENSUS: 12DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Susana Harmon (Administrator)TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Susana Harmon (Administrator) and explained the purpose of the visit. The facility is licensed to serve: TWELVE (12) NON-AMBULATORY CLIENTS. HOSPICE WAIVER APPROVED FOR THREE (3) RESIDENTS.

A tour of the single story facility contains the following: Living room, kitchen, dining room, 12 resident bedrooms, 6 bathrooms and a sun room.

During today’s visit, LPA observed the following: Physical Plant and Environmental Safety: Sufficient lighting, non-skid maps in all bathrooms, comfortable temperature, hot water temperature measured between 105 degree F to 120 degree F in the bathroom, all bathing facilities in operable condition, no bodies of water on the premises, no firearms on the premises, toxins stored inaccessible to residents. Smoke detectors/Carbon monoxide detectors are operable. Fire extinguisher mounted to the kitchen wall is fully charged. Operational Requirements: Facility has an approved fire clearance for non-ambulatory persons. Staffing: There is sufficient staff, the administrator is on the premises during normal business hours. Personnel Records - Training: Staff has criminal record clearance, staff have sufficient hours of training which includes current First aid/CPR training. Resident Records/Incident Reports: Admission agreement, medical assessment and appraisal observed. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities, furnished areas is provided for relaxation of residents. Food Services: Perishable foods are stored in covered containers, toxins are stored separate from foods, kitchen is kept clean. Incidental Medical and Dental: Licensee provide assistance in meeting medical and dental needs for residents, all centrally stored medications is labeled and maintained in compliance with state and federal law. Disaster Preparedness: Last disaster drill was conducted and document on 09/23/22.

No deficiencies were observed during today's visit.


An exit interview was conducted and a copy of this report was provided to Susana Harmon.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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