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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600731
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:55:48 PM

Document Has Been Signed on 07/14/2022 03:55 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:GABRIELLA MOTHERLY CAREFACILITY NUMBER:
198600731
ADMINISTRATOR:VIVIAN ORTIZ-LUISFACILITY TYPE:
735
ADDRESS:3249 GABRIELLA STREETTELEPHONE:
(626) 964-6665
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 2DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Victor Taclob, StaffTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Victor Taclob and explained the purpose of the visit. The facility is licensed for four (4) level 3 non-ambulatory developmentally disabled clients ages 18-59 years old. The facility is serviced by the San Gabriel/Pomona Regional Center. The facility is a single story home located in a residential neighborhood. It consists of 4 client bedrooms, 2 bathrooms, kitchen, dining room, living room, laundry area in attached garage, and outdoor shaded patio area. The last emergency disaster drill was conducted on 1/18/2022. Administrator certificate expires 5/18/2024.

Observations:
  • COVID-19 Infection Control signs were observed in the entrance, bathrooms, and throughout the facility.. Screening protocols are in place. The facility has an approved mitigation plan.
  • Staff was observed wearing a mask. Clients in care do not wear a mask due to cognitive impairment.
  • Each client bedroom is designated as a COVID-19 isolation room if needed.
  • Two (2) centrally stored resident medication records were reviewed. Facility maintains a 30-day supply of medications. Centrally stored medications are kept in a locked closet.
  • Sharps and chemicals/cleaning supplies are stored inaccessible to residents.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed. Smoke detectors were tested and are operational. Fire extinguishers are fully charged. The facility has a fire pull alarm system.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.

*** NOTE: Facility shall submit Infection Control Plan to CCL.

No deficiencies cited.


Exit interview was conducted with Staff Victor Taclob. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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