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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803338
Report Date: 11/05/2021
Date Signed: 11/05/2021 05:22:02 PM

Document Has Been Signed on 11/05/2021 05:22 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:EXCEL ADULT HOMESFACILITY NUMBER:
197803338
ADMINISTRATOR:HELAL, SANAAFACILITY TYPE:
735
ADDRESS:133 NORTH EL MOLINOTELEPHONE:
(626) 300-9050
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 4CENSUS: 4DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Sanaa Helal, licenseeTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an annual inspection with the focus of the Infection Control domain. LPA arrived unannounced and explained the purpose of the visit to the staff who allowed entry. Licensee, Sanaa Helal, arrived shortly thereafter. The facility is licensed for four (4) Ambulatory Developmentally Disabled Adults from 18-59 years old.

LPA Chan toured the facility with licensee and observed/inspected the following:
* The facility has 3 Client bedrooms, 2 Client bathrooms, living room, dining room, family room, kitchen, laundry area, staff rest area, restroom designated for staff use, and a detached garage. The detached garage space has been converted to a living space. Per licensee, it has been permitted and will be designated for a live-in staff.
* Signage such as proper hand washing, germs, and covid-19 related information are posted in the facility.
* There is a functional smoke detector in every room and one carbon monoxide detector in the house.
* The hot water temperature was measured within the range of 105-120 degree F.
* Disinfectants are stored and locked in a cabinet by the laundry room. Knives are stored and locked in a small security box in the kitchen cabinet.
* Sufficient food supply of 2-day perishable and a week of nonperishable were observed.
* There are no bodies of water or pool at the facility. No items obstructing the walkways.
* Medications were reviewed for 3 of the 4 clients and are given as prescribed.

There are no deficiencies observed during the visit. An exit interview was conducted. A copy of this report along with the appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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