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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600336
Report Date: 01/30/2024
Date Signed: 01/30/2024 04:46:39 PM

Document Has Been Signed on 01/30/2024 04:46 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:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Manuelita Reyes, administratorTIME COMPLETED:
05:00 PM
NARRATIVE
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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. Annual fees are current.

During the visit, the following domain of the new inspection tool was used; interviewed staff/clients; 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. Medications are properly logged and current. No pools or large bodies of water at the facility. Passageways are free of obstruction. Last disaster drill is conducted on 1/27/24.

Deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. An exit interview was conducted. LIC 809 and LIC 809D reports and Appeal rights were discussed and provided to Administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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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Document Has Been Signed on 01/30/2024 04:46 PM - It Cannot Be Edited


Created By: Bonnie Tao On 01/30/2024 at 03:39 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
(a) (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
LPA and administrator Manuelita observed live cockroaches crawled across the dining table and stove top in the facility kitchen.
Deficient Practice Statement
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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: 02/07/2024
Plan of Correction
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Licensee will maintain a contract with pest control company to address the pest problem, until the facility is free of cockroaches.

Administrator will provide LPA with detailed reports until the facility is free of pest issue. The administrator would ensure to comply with all recommendations given by pest control company if that is needed. Due on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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