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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600857
Report Date: 08/12/2022
Date Signed: 08/12/2022 11:06:06 AM

Document Has Been Signed on 08/12/2022 11:06 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOODMAN RESIDENTIAL HOME, INC.FACILITY NUMBER:
198600857
ADMINISTRATOR:LARRY S GOODMANFACILITY TYPE:
735
ADDRESS:897 E JEFFERSON AVETELEPHONE:
(909) 622-6843
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 6DATE:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:S-1 TIME COMPLETED:
11:00 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 S-1 and explained the purpose of today's visit. Administrator arrived at approximately 9:30 A.M..

This is a single home with (3) bedrooms, (1) bathroom, kitchen, dinning area, living room and an attached garage.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices were observed at the entrance of this facility and throughout the facility. COVID signs were throughout the facility.
  • Bathrooms had hand soap and hand sanitizer.
  • PPE and hygiene supplies observed. Additional supplies are stored inside the garage.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supplies are stored inside the garage.
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.
  • Medication reviewed for (6) Clients (Client #1 through Client #6).
  • Per S-2, (6) clients have both COVID vaccines and have the booster.
  • Per S-2, (7) staff have both COVID vaccines and have the booster.

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: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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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