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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600142
Report Date: 06/27/2022
Date Signed: 06/27/2022 11:10:11 AM

Document Has Been Signed on 06/27/2022 11:10 AM - 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:ALVARADO ADULT HOME, LLCFACILITY NUMBER:
198600142
ADMINISTRATOR:RAHMAAN, ALMAFACILITY TYPE:
735
ADDRESS:1071 EAST ALVARADO AVENUETELEPHONE:
(909) 622-1859
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:S-1TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and discussed the purpose of today's visit. All clients residing at this receive Case Management services provided by San Gabriel Pomona Regional Center. All clients residing in this home are between the ages of 18 through 59.

This facility consists of (3) bedrooms, (2) bathrooms, kitchen, dinning area, living room, den and detached garage.

The following were observed/inspected: .
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility
  • PPE supplies observed.
  • Restrooms have hand soap and paper towels.
  • Hand sanitizers observed.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Per S-1, all (4) clients have both vaccines and 1st booster.
  • Per S-1, there are (6) staff members have both vaccines and 1st booster.
  • Medication reviewed for (3) Clients (Client #1, Client #3 and Client #4). Client #2 does not take medication.
  • Staff responsible for direct care and supervision will wear masks.

Per Administrator, the infection control plan has been submitted to CDSS. Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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