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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601049
Report Date: 01/23/2024
Date Signed: 01/23/2024 04:55:16 PM

Document Has Been Signed on 01/23/2024 04:55 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:SUNGLOW HOMEFACILITY NUMBER:
198601049
ADMINISTRATOR:OBSTACULA, CRISTINAFACILITY TYPE:
735
ADDRESS:9734 SUNGLOW STREETTELEPHONE:
(562) 948-1681
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 4CENSUS: 3DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Staff#1TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with staff#1, who assisted with the visit. The facility serves four (4) developmental disabled, ambulatory clients, age 18 through 59 years old. All current clients were placed by Eastern LA Regional Center. LPA discussed with administrator over the phone and staff at the facility regarding the purpose of today's visit and the inspection.

During the visit, the new inspection CARE tool was used; a tour of the facility was conducted; food supply was reviewed; staff/clients files were reviewed; staff/clients interviews were conducted; and medications were reviewed. The facility is a single family home consists of four (4) clients bedrooms, two (2) bathrooms, dining room with activity area, kitchen, living room, laundry room, and patio with a covered patio area. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have the required furniture and in compliance. Lamps/lights for each room are available. Adequate linen and personal hygiene supply are observed. Hot water temperature was measured at 114.3 degrees Fahrenheit which was within Title 22 Regulation guidelines. Smoke detectors and carbon monoxide detectors are operable. Medications are centrally stored and locked. Medications are properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguisher is fully charged. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. The front yard is well maintained. No pools or large bodies of water at the facility. Passageways are free of obstruction.

No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. An exit interview was conducted. This report was discussed with Staff#1 and report LIC 809s are provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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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