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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600767
Report Date: 11/24/2021
Date Signed: 11/24/2021 01:17:18 PM

Document Has Been Signed on 11/24/2021 01:17 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:MALMQUIST HOMEFACILITY NUMBER:
198600767
ADMINISTRATOR:MARIA DEVOREFACILITY TYPE:
735
ADDRESS:2821 MELBOURNE AVETELEPHONE:
(909) 621-4653
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 6DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:S-1/Facility AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and explained the purpose of today's visit.

This home consists of (6) private client bedrooms, (3) bathrooms, living room, kitchen, dinning area, exercise/laundry room. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. LPA toured grounds.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE and Hygiene supplies observed.
  • Restrooms have hand soap, hand sanitizer and paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. This facility has (2) refrigerators.
  • Per Administrator, all (6) clients are fully vaccinated including the booster vaccine.
  • Per Administrator, all staff are fully vaccinated and some staff are pending the booster.
  • Per Administrator, all clients and staff have received their flu vaccine.
  • Medication reviewed for (6) Clients (Client #1 through Client #6).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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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