197803078-10-31-2023-28-AS-KRAZ-CX5RD7-20231031125527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803078
Report Date: 10/31/2023
Date Signed: 10/31/2023 12:55:45 PM

Document Has Been Signed on 10/31/2023 12:55 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:	SAN GABRIEL VALLEY TRAINING CENTER		FACILITY NUMBER:	197803078
ADMINISTRATOR:	HARMON, SUSANA		FACILITY TYPE:	740
ADDRESS:	339 S. COVINA BLVD.		TELEPHONE:	(626) 369-3398
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91746
CAPACITY:	12	CENSUS: 12	DATE:	10/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Susana Harmon		TIME COMPLETED:	01:10 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

LPA OBSERVATIONS: Tour began at 8:31 am and was led by Administrator Harmon. The facility is divided into two (2) single-story building units located in a residential area. Each building unit (A & B) contain: two (2) live-in staff bedrooms, one (1) staff bathroom, one (1) staff kitchen, twelve (12) client bedrooms, six (6) Jack & Jill style bathrooms, client kitchen, dining room, living room, and linen closets.

Unit A Building: (Female only)

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to twelve (12) out of twelve (12) residents in care. Resident kitchen sink water temperature was measured at 109.9 degrees F. Signs promoting hand washing were observed in this area.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting. LPA Ramirez observed mini fridge in this area to be accessible and contain snacks and several beverages. LPA Ramirez observed fully charged fire extinguisher in dining room area.

Linen Closet/Emergency Supply Cabinet: Contained plenty linens, towels, and hygiene products. LPA Ramirez observed emergency supplies in cabinet.

Resident Rooms 8 - 12: LPA Ramirez inspected all resident bedrooms. All resident bedrooms were observed to contain the required linens, furnishings, and lighting. LPA Ramirez observed all resident bedrooms to be clean and did not observe any hazards during visit.

SEE 809-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: SAN GABRIEL VALLEY TRAINING CENTER	FACILITY NUMBER: 197803078
	VISIT DATE: 10/31/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident Bathrooms: All resident bathrooms observed to be clean. LPA Ramirez observed signs promoting proper handwashing procedures. Water temperature in resident bathroom# 7&8 was measured at 116.7 degrees F which is in the required 105 – 120 degrees F. Resident bathroom#9&10 was observed to be clean and water temperature was measured at 114.7 degrees F which is in the required 105 – 120 degrees F.

Centrally Stored Medications: LPA observed cabinet located in kitchen cabinet to be locked and inaccessible to residents in care. LPA Ramirez reviewed six (6) resident medications and did not find any discrepancies.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed.

Fire/Disaster Drill: Proof of last documented fire drill was conducted 09/06/23 at 7pm and 08/17/23 at 7pm.

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 and tested during visit. LPA Ramirez observed several fully charged fire extinguishers throughout the facility.

Personnel Records: Staff records are maintained at facility. Five (5) staff records were reviewed. LPA Ramirez reviewed current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file, Criminal record clearance, and initial training.

Resident Records: Twelve (12) resident records were reviewed. Admissions agreements, resident personal rights, and recent (2023) Individual Personal Plan (IPP) were observed in files.

Infection Control Plan/Liability Insurance: LPA Ramirez received a copy of Infection Control Plan last updated 5/19/2023 and received a copy of current liability insurance. LPA Ramirez reviewed four (4) current facility vehicle registrations.

SEE 809-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SAN GABRIEL VALLEY TRAINING CENTER	FACILITY NUMBER: 197803078
	VISIT DATE: 10/31/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Unit B Building: (Male only)

Linen Closet/Emergency Supply Cabinet: Contained plenty linens, towels, and hygiene products. LPA Ramirez observed emergency supplies in cabinet.

Resident Rooms 1 - 6: LPA Ramirez inspected all resident bedrooms. All resident bedrooms were observed to contain the required linens, furnishings, and lighting. LPA Ramirez observed all resident bedrooms to be clean and did not observe any hazards during visit.

Resident Bathrooms: All resident bathrooms observed to be clean. LPA Ramirez observed signs promoting proper handwashing procedures. Water temperature in resident bathroom# 1&2 was measured at 109.9 degrees F which is in the required 105 – 120 degrees F. Resident bathroom #3&4 was observed to be clean and water temperature was measured at 109.6 degrees F which is in the required 105 – 120 degrees F.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3