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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600522
Report Date: 03/20/2024
Date Signed: 03/20/2024 02:08:39 PM

Document Has Been Signed on 03/20/2024 02:08 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:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Priscilla Nanong, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met administrator Priscilla Nanong, who assisted with the visit. The facility is licensed to serve six (6) Developmentally Disabled Adult clients (ages 18-59), ambulatory only. LPA discussed the purpose of today's visit and the inspection to administrator.

During the visit, LPA completed Care tool, conducted physical plant, interviewed staff/clients, reviewed food supply, reviewed staff/clients files and medications.

The facility is a single family home located in a residential neighborhood. Facility consists of three (3) bedrooms, staff room, office, two (2) bathrooms, living room, dining room, kitchen, laundry area, 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 and back yard are in compliance with Title 22. 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. Hot water temperature measured at 119.7 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 3/18/24. Medications are centrally stored, locked and the records are current. Hazardous items are locked and inaccessible to clients. Annual fees are current.

No deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed with administrator. A copy of LIC 809 report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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