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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600875
Report Date: 09/21/2021
Date Signed: 09/30/2021 08:43:11 AM

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:CANDLELIGHT HOME, BARTLETTFACILITY NUMBER:
198600875
ADMINISTRATOR:JANE ANNE CUAFACILITY TYPE:
735
ADDRESS:3216 BARTLETT AVETELEPHONE:
(626) 927-9253
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:4CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gil CalingasanTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Annual continuation inspection at the facility and met with Administrator Gil Calingasan to discuss the purpose of todays visit, Prior to entering the facility, LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 626 927 9253.

The facility consist of two bedrooms, two bathrooms, a living room, dining room, office, kitchen and patio located in the back yard, unattached garage(storage and overflow of food).

On 08/30/21 LPA conducted a complete tour of the facility, and observe the supply of food. During todays visit, the Infection control domain was completed and the following areas were observed/inspected: The facility had all postings at the front/back entrance, bathrooms, and throughout the facility. A Pre screening area with PPE supplies was observed upon entry into the facility. The mitigation plan was received and approved on 06/04/2021.

Resident medications, and medication logs were reviewed. Smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the kitchen and one in the living room. The water temperature was tested and measured 112.6 degrees F.

Administrators certificate for Gil D. Calingasan #6045826735, expires on 11/20/2021.

There were no deficiencies cited during todays visit, and a copy of this report was given during the exit interview.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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