198600951-5-31-2022-28-AS-NMAN-CEXUR7-20220531154815

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600951
Report Date: 05/31/2022
Date Signed: 05/31/2022 03:48:21 PM

Document Has Been Signed on 05/31/2022 03:48 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:	HARLAN RESIDENCE		FACILITY NUMBER:	198600951
ADMINISTRATOR:	JARAMILLO, JESSICA M.		FACILITY TYPE:	735
ADDRESS:	4133 HARLAN AVENUE		TELEPHONE:	(626) 338-0526
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY: 4		CENSUS: 4	DATE:	05/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator Marcos Hernandez		TIME COMPLETED:	03:50 PM

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Licensing Program Analysts (LPA) Nune Margaryan conducted an annual required visit. LPAs met with Administrator Marcos Hernandez and explained the reason for the visit. LPAs used the infection control tool to evaluate the facility. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and resident and staff records. The facility has an approved mitigation plan on file. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center.
LPA toured the home and inspected three (3) client bedrooms, two (2) bathrooms, kitchen, dining room, the den, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded seating area for the clients located in the backyard. LPA observed laundry detergent locked in the garage and not accessible to clients.
There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.
Client bedrooms were checked. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked in a kitchen cabinet inaccessible to clients.

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SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HARLAN RESIDENCE	FACILITY NUMBER: 198600951
	VISIT DATE: 05/31/2022

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LPA observed the centrally stored medication area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The carbon monoxide detector was observed in the living room and working properly. Fire extinguisher was fully charged and operational.

LPA reviewed resident files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.
Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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