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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600767
Report Date: 10/13/2022
Date Signed: 02/06/2023 10:02:17 AM

Document Has Been Signed on 02/06/2023 10:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Nicole Lian/S-1TIME COMPLETED:
11:45 AM
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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 Nicole Lian/S-1 and explained the purpose of today's visit.
LPA conducted a facility tour. This home consists of (6) private client bedrooms, (3) bathrooms, living room, kitchen, dinning area, exercise/laundry room. San Gabriel Pomona Regional Center provides case management services for all (6) clients residing at this facility.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed inside a large storage chest.
  • Hygiene and incontinence supplies observed.
  • Restrooms have hand soap, hand sanitizer and paper towels. Hand washing signs were observed posted in all (3) bathrooms.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Facility has (2) refrigerators that are fully stocked.
  • Medication reviewed for (6) Clients (Client #1 through Client #6).
  • Per S-1, all (6) clients are fully vaccinated including the booster vaccine.
  • Per S-1, all clients have their annual flu vaccine pending.
  • 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 Nicole Lian/S-1.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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