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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803338
Report Date: 09/13/2022
Date Signed: 09/13/2022 01:11:05 PM

Document Has Been Signed on 09/13/2022 01:11 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:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Sanaa Helal, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA met with the Administrator, Sanaa Helal, who arrived at 11:45 a.m. to assist with the inspection. The facility is licensed to serve four (4) developmentally disabled adults ages 18 - 59 and approved for 4 non-ambulatory clients.

LPA toured the facility with the Administrator and observed the following:
* There are 3 client bedrooms, 3 bathrooms (2 for client use and 1 for staff), living room, dining room, family room, kitchen, laundry area, and staff rest area, and a detached garage.
* Temperature is taken upon entering the facility and is documented.
* Coronavirus (COVID-19) signage are posted throughout the facility to promote hand washing hygiene, cough/sneeze etiquette, and symptom checks.
* The facility has at least 30 days of PPE supplies in storage.
* There are sufficient food supply of 2 day perishable and a week of non-perishable.
* Knives, cleaning solutions, and disinfectants are stored and locked making them inaccessible to clients.
* Smoke detectors and a carbon monoxide detector were tested and operable.
* Medications are centrally stored and locked in the cabinet. LPA reviewed medication for all 4 clients.
Per the Administrator, they are continuing to follow the COVID-19 guidance.

No deficiencies were observed during the visit today. An exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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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