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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600271
Report Date: 06/09/2022
Date Signed: 06/09/2022 02:30:38 PM

Document Has Been Signed on 06/09/2022 02:30 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:HAMILTON VILLAFACILITY NUMBER:
198600271
ADMINISTRATOR:ADELA SANTOSFACILITY TYPE:
735
ADDRESS:948 SOUTH HAMILTON BLVD.TELEPHONE:
(909) 620-1933
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 84CENSUS: 50DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Adela SantosTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPA) Elizabeth Irra conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Facility Administrator and explained the purpose of the visit.

This facility consists of four (4) single-story buildings which accommodates 12 double-occupancy rooms each. There is also building which consists of the medication room, offices, activities room, main storage room and laundry room and a kitchen with dinning area.
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, in common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Facility has one (1) designated isolation room in each building (with occupancy for 2 clients each) available if a COVID-19 positive case should arise.
  • Medications for (5) Clients were reviewed.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • Per Administrator: there are (38) clients that have both vaccines and the 1st booster, (11) clients have both vaccines only and boosters are pending and (1) client refused the vaccine.
  • Per Administrator, there are (14) staff and all have both vaccines and the 1st booster.
  • Additional PPE supplies and hygiene supplies observed inside the storage room.
  • Hand Sanitizers observed in the medication room, dinning room and office.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • LPA discussed the Infection Control Plan which will be sent to CDSS.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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