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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600314
Report Date: 03/18/2024
Date Signed: 03/18/2024 11:10:39 AM

Document Has Been Signed on 03/18/2024 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:HOUSE ON GARO, THEFACILITY NUMBER:
198600314
ADMINISTRATOR:STALLCUP-DOBRENEN, CARRIEFACILITY TYPE:
735
ADDRESS:15463 GARO STREETTELEPHONE:
(626) 369-0099
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 4DATE:
03/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:House Manager Nick Baez TIME COMPLETED:
11:20 AM
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Licensing Program Analyst(s) (LPA) Jose Villalobos and Tyler Reyes conducted an unannounced Annual Continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with House Manager Nick Baez and the purpose of the visit was discussed. The following (CARE) tool domains were utilized during todays inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan for LPA to review.

Staffing:
  • Sufficient staff observed to meet clients needs
  • Facility currently provides care and supervision for a total of four (4) Clients.

Personnel Records-Training:
  • Administrator on record is current
  • Staff have criminal background clearance and training.
  • Five (5) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR and CPI training was observed. Staff file have criminal record clearances and are associated.

Client Records-Incident Reports:
  • A total of Four (4) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.

Health Related Services:
  • Four (4) Client centrally stored medications were reviewed.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE ON GARO, THE
FACILITY NUMBER: 198600314
VISIT DATE: 03/18/2024
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Incident Medical and Dental:
  • (0) Clients have prohibited or restricted health condition.
  • (0) Clients with Staph or other Serious, Communicable infections

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610 is in place. Facility to complete new LIC 610D

Emergency intervention:
  • No use of manual restraint or seclusion was observed. Emergency Intervention staff training not needed

All (12) domains have been completed as of todays visit. Per California Code of Regulations, Title 22, No deficiencies are being cited, but facility was provided a technical violation. Exit Interview Conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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