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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600460
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:00:04 PM

Document Has Been Signed on 07/02/2024 04:00 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:MONTEBELLO HOMEFACILITY NUMBER:
198600460
ADMINISTRATOR/
DIRECTOR:		OBSTACULO, CRISTINAFACILITY TYPE:
735
ADDRESS:740 SOUTH MONTEBELLO BLVD.TELEPHONE:
(323) 477-1543
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 6CENSUS: 6DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Cristina ObstaculoTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Caregiver Manuel Suyat and explained the reason for the visit. Shortly thereafter Administrator Cristina Obstaculo arrived. The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Caregiver Manuel Suyat today 07/02/2024 at 1:45 PM and the following was observed
Facility contains 3 Client Bedrooms and 2 client bathrooms dining room, kitchen, and TV room.
All staff had criminal clearance and were associated.
Required Annual Inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Training, Client Rights- Information, Client Records- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained. Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed and was given per physician's directions. 4 Client Files and 4 Staff Files were reviewed.
Disaster Drill was conducted on 07/01/24.
Interviews were not conducted because there was a computer error in which LPA could not access the interviews.
No deficiencies. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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