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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600271
Report Date: 06/23/2023
Date Signed: 06/23/2023 01:49:35 PM

Document Has Been Signed on 06/23/2023 01:49 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: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: 64DATE:
06/23/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Adela SantosTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to complete the annual inspection. The initial inspection was conducted on 06/22/2023. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and completed the remaining domains:

Physical Plant & Environment Safety: Smoke alarms and signal system were tested and operable. Fire extinguishers are located throughout the facility (each hallway of every unit) with a last service date 03/15/23. Carbon monoxide detectors are located throughout the facility (each hallway of every unit/tested and operable). Hot water supply measured within 106.5* to 112.0*. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Additional food supply is stored inside the storage room near the medication room. Per Administrator, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored inside the medication room. LPA reviewed medication for C-1 through C-6. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610/9 pages) in place.
Emergency Intervention: Per Administrator, staff do not use manual restraints nor seclude clients.

Exit interview, appeals rights and a copy of this report was provided to Adela Santos. Note: LPA was experiencing technical problems during this visit.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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