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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600686
Report Date: 05/12/2022
Date Signed: 05/12/2022 03:12:11 PM

Document Has Been Signed on 05/12/2022 03:12 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:JML BOARD & CAREFACILITY NUMBER:
198600686
ADMINISTRATOR:FIERRO, GILBERTFACILITY TYPE:
735
ADDRESS:191 EAST WASHINGTON BLVD.TELEPHONE:
(626) 797-5022
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Staff / Gilbert Guerra
Administrator / Gilbert Fierro		TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff / Gilbert Guerra and was later joined by the Administrator / Gilbert Fierro who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled Clients ages 18 - 59 years of age. The facility is approved for four (4) Ambulatory Clients only. Currently, there are four (4) clients in placement, of which 1 is in rehab due to a fractured tibia. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

The facility is located in a residential area. A tour of the single-story facility includes: Four (4) client bedrooms, 1 (one) staff room, three (3) bathrooms (one of which is located in the garage), living room, kitchen / dining area, laundry room and indoor/outdoor activity areas. The staff room is kept locked and inaccessible to clients at all times. All medications for clients who need assistance are kept locked and inaccessible to other clients. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to residents. LPA reviewed client medications.

Smoke detectors and carbon monoxide detectors are operable and in compliance. LPA observed a pull-switch fire alarm in the living room. The fire extinguisher was observed in the kitchen area and was fully charged. The first-aid kit is fully stocked w/First-aid Manual. The front yard is well landscaped with steps that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and
debris and the trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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: JML BOARD & CARE
FACILITY NUMBER: 198600686
VISIT DATE: 05/12/2022
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nor weapons on the premises. There is a detached garage which is kept locked and inaccessible to clients at all times.

No deficiencies were observed during this visit
An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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