<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600336
Report Date: 02/08/2022
Date Signed: 02/08/2022 04:54:13 PM

Document Has Been Signed on 02/08/2022 04:54 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:CONWELL RESIDENTIAL FACILITYFACILITY NUMBER:
198600336
ADMINISTRATOR:REYES, MANUELITA V.FACILITY TYPE:
735
ADDRESS:4656 NORTH CONWELL AVENUETELEPHONE:
(626) 332-0190
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 5DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Manuelita Reyes, Administrator TIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with Licensee/ Administrator Manuelita Reyes, who assisted with visit. The facility is licensed to serve six (6) Mentally Disabled Adults (ages 18-59), Ambulatory only. LPA discussed with administrator regarding the purpose of today's visit and the inspection.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility was conducted; food supply was reviewed; and medications were reviewed.

The facility is a single story home located in a residential neighborhood. LPA observed the facility to have three (3) client bedrooms, one (1) caregiver bedroom, two (2) bathrooms, living room, dining room, kitchen, laundry area in the patio, attached garage and indoor/ outdoor activity area.

Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Backyard has a covered trash can. Smoke detectors and Carbon monoxide detectors are operable. Medications are centrally stored and locked.

(- continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 02/08/2022 04:54 PM - It Cannot Be Edited


Created By: Bonnie Tao On 02/08/2022 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CONWELL RESIDENTIAL FACILITY
FACILITY NUMBER: 198600336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

The requirement is not met as evidenced by:

Water temperature is measured at 145.5 degree Fahrenheit at the kitchen sink.
Trash, debris and old furniture were piled up at the side yard.
The stove top burner on the front left side of the stove is not working.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2022
Plan of Correction
1
2
3
4
Administrator will ensure the water temperature will remain in a range of 105 - 120 degree Fahrenheit; left front stove burner will be working; and trash and hazard in side yard will be removed. Plan of Corrections (POC) must be corrected by POC date
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CONWELL RESIDENTIAL FACILITY
FACILITY NUMBER: 198600336
VISIT DATE: 02/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Medications are properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguisher is fully charged. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. The front yard is well maintained. No pools or large bodies of water at the facility. Passageways are free of obstruction. Last disaster drill is conducted on 2/1/22. Administrator certificate is current, expires on 7/28/23. Annual fee is current.

Deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. Appeal right was provided.

An exit interview was conducted. This report was discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3