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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600271
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:58:32 PM

Document Has Been Signed on 06/20/2024 02:58 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/
DIRECTOR:		ADELA SANTOSFACILITY TYPE:
735
ADDRESS:948 SOUTH HAMILTON BLVD.TELEPHONE:
(909) 620-1933
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 84CENSUS: 64DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Adela SantosTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Adela Santos and discussed the purpose of today’s visit.

This facility consists of four (4) single-story buildings which accommodates (12) double-occupancy rooms each. There is also a building which consists of the medication room, offices, activities room, main storage room and laundry room and a kitchen with dining area.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control Plan in place.

Physical Plant & Environment Safety: Smoke/Carbon Monoxide observed. Fire extinguishers are located throughout the facility with a last service date 03/05/24. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Operational Requirements: The fire clearance is approved for (78) ambulatory and (6) non-ambulatory clients. Staff are adhering to operational requirements.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Adela Santos expires on 07/14/24. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) through Staff # (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.
**Refer to LIC 809C for the continuation of this report**
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VILLA
FACILITY NUMBER: 198600271
VISIT DATE: 06/20/2024
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Client Rights-Information: Client rights are posted and included in Client files. Per Administrator, there are no clients with postural supports.

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. 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.
Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #6 (C-6). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent For Medical Treatment, Appraisal/Needs and Services Plan, Functional Capabilities Assessment, Resident Appraisal, House Rules, and Client Rights were observed.

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.

Incidental Medical Services: Per Administrator, there are (0) clients with restricted health condition plans and (0) clients with prohibited conditions.

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 provided Facility Administrator with Title 22, Section 85068.4 Acceptance and Retention Limitations regulations (Advisory Note provided).
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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