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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600857
Report Date: 11/05/2024
Date Signed: 11/05/2024 02:00:46 PM

Document Has Been Signed on 11/05/2024 02:00 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOODMAN RESIDENTIAL HOME, INC.FACILITY NUMBER:
198600857
ADMINISTRATOR/
DIRECTOR:		LARRY S GOODMANFACILITY TYPE:
735
ADDRESS:897 E JEFFERSON AVETELEPHONE:
(909) 622-6843
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 6DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Dennely Zarazua/S-1TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Elizabeth Irra and Mayra Cota conducted the required annual inspection. LPA met with Dennely Zarazua/S-1 and discussed the purpose of today’s visit.

This home consists of (3) bedrooms, (1) bathroom, kitchen, dining area, living room and an attached garage. All clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center. This home is approved for (6) ambulatory clients.

LPA utilized the Compliance and Regulatory (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control plan in place.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detector tested and operable. Fire extinguishers appear to be full (laundry/kitchen and living room). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: LPA reviewed staff files for Staff #1 (S-1) and Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis.

Refer to LIC 809C for the continuation.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOODMAN RESIDENTIAL HOME, INC.
FACILITY NUMBER: 198600857
VISIT DATE: 11/05/2024
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Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #6 (C-6). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and locked inside a cabinet. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per S-1, there are (0) clients with a restrictive health plan, (0) client utilizing postural supports and (0) clients with prohibited health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan in place.

Exit interview, appeals rights and a copy of this report was provided to Lauren Goodman.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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