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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600522
Report Date: 03/28/2022
Date Signed: 03/28/2022 01:01:47 PM

Document Has Been Signed on 03/28/2022 01:01 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:PKD GROUP HOMEFACILITY NUMBER:
198600522
ADMINISTRATOR:NANONG, PRISCILLA T.FACILITY TYPE:
735
ADDRESS:1127 NO. BARRANCA AVENUETELEPHONE:
(626) 332-0815
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Priscilla Nanong, Administrator
Joshua Santos, staff		TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with Staff, Joshua Santos, who contacted the Administrator. About 45 minutes after, the Administrator, Priscilla Nanong arrived to assist with visit. The facility is licensed to serve six (6) Developmentally Disabled Adult clients (ages 18-59), Ambulatory only. Currently, there are six (6) clients in placement. LPA discussed with administrator regarding the purpose of today's visit and the inspection.

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

The facility is a single-story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. Facility consists of three (3) bedrooms, a staff room/office, two (2) bathrooms, living room, dining room, kitchen, laundry room, garage and an indoor/outdoor activity area. Client rooms are furnished with appropriate furniture for clients’ comfort. Bathrooms are operational and furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the clients. A shaded area with chairs is provided in the back yard. The yard is free of debris/ hazard, and there are covered trash cans. Sufficient supply of perishable and nonperishable foods is observed.

Smoke detectors and carbon monoxide detector are operable and in compliance. Fire extinguishers are fully charged. The first aid kit is fully stocked. Hot water temperature measured at 110.7 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are observed. The last Fire/ Emergency Drill was conducted on 03/20/22. Medications are centrally stored, locked and the records are current. Hazardous items are locked and inaccessible to clients. Annual licensing fees are current.
(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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: PKD GROUP HOME
FACILITY NUMBER: 198600522
VISIT DATE: 03/28/2022
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No deficiencies were observed per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with Administrator, Priscilla Nanong, who’s signature on this form confirm receipt of these documents. A copy of LIC 809 report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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