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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600717
Report Date: 07/01/2024
Date Signed: 07/01/2024 04:01:10 PM

Document Has Been Signed on 07/01/2024 04:01 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:FRANCISQUITO HOMESFACILITY NUMBER:
198600717
ADMINISTRATOR/
DIRECTOR:		TUASON, CYNTHIAFACILITY TYPE:
735
ADDRESS:15704 EAST FRANCISQUITO AVENUETELEPHONE:
(626) 918-6712
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 6DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Administrator Cynthia Tuason TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met Administrator Cynthia Tuason and the purpose of the visit was discussed.
The following twelve (12) tool domains were completed during the visit:
1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing and self symptom check of staff and visitors. The facility has an Infection Control Plan in place. LPA collected a copy

2. Physical Plant & Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, small staff office, four (4) clients bedrooms and two (2) bathrooms, staff break room, storage room and a detached garage. Bedroom#1 and #4 are for (2) Clients each and have required furniture. Bedroom#2 and #3 are for (1) client each and were also observed to have required furnishings. The bathrooms are clean, sanitary and in a good working condition. The hot water temperature tested in both bathrooms to be within Title 22 regulations. The passageway, walkway and patio are free of obstruction. Closet space observe for linen supply and hygiene products. The facility has night light in the hallway. The facility also has telephone services in the premises. The sharp knives/utensils as well as the toxins/cleaning supplies are stored inaccessible to clients in care. All the appliances are operational. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all working well.

3. Operational Requirement: The facility is approved for serve Developmentally Disabled Adults 18-59 years old and ambulatory only. The facility is licensed as a level 4C vendored by San Gabriel Pomona Regional Center. The clearance is for (6) ambulatory clients. The last fire/disaster drill was conducted on 3/13/24.

4. Staffing: There was sufficient staffing observed in the facility during the visit. The night supervision staff also have the required training for the planned emergency procedure.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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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: FRANCISQUITO HOMES
FACILITY NUMBER: 198600717
VISIT DATE: 07/01/2024
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5. Personnel Record-Training: All the staff files are maintained and stored in the facility. All the staff are associated and fingerprint cleared with the facility. The facility administrator is Cynthia Tuason and her administrator certificate is going to expire on 10/21/2024. Administrator has completed required trainings. LPA reviewed (5) Staff files and all have the required documents in their personnel files.

6.Client's Rights -Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.

7.Client Records-Incident Reports: All clients files are maintained in the facility and stored inaccessible to clients in care. LPA reviewed (6) of (6) Client Files. All files have the required documents which include: face sheet, admission agreement, physician report, ambulatory status, current medication list...etc

8. Food Services: Facility has sufficient food supply is stored in the kitchen consisting of: 2-day perishables, 7-day non-perishables. The refrigerator is maintained in the required temperature. All the food are stored probably. Special diet plan observed for (1) of (6) clients in care.

9. Health Related Servicers: The medication is centrally stored and locked. LPA inspected all six (6) clients' medication and they are all accurate and updated. LPA also inspected the first aid kit and its stored and locked in the medication cabinet, and they all have the required supplies in the kit.

10. Incidental Medical Services: Currently the facility has no client with prohibited health condition or restricted health condition.

11. Disaster Preparedness: Emergency and Disaster Plan LIC 610D is in place and the facility also has two alternative temporary shelter location.

12. Emergency Intervention: Its not applied to the facility. No restraints are in use at this facility.

No deficiencies were observed during the visit.

Exit Interview conducted. The copy of the report was provided to administrator Cynthia Tuason
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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