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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601183
Report Date: 12/19/2022
Date Signed: 02/06/2023 09:59:24 AM

Document Has Been Signed on 02/06/2023 09:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ENGLISH FAMILY CARE HOME, INC.FACILITY NUMBER:
198601183
ADMINISTRATOR:BRENDA SEABORNFACILITY TYPE:
735
ADDRESS:984 RUSSELL PLACETELEPHONE:
(909) 620-1741
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 2DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brenda SeabornTIME COMPLETED:
11:30 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 was allowed entry by Brenda Seaborn and explained the purpose of today's visit.

This home consists of (5) bedrooms, (3) bathrooms, living room, kitchen, dinning area and office. All clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Bathrooms have hand washing soap, paper towels and hand washing etiquette signs.
  • Each Client has their own bedroom.
  • Medication reviewed for Client #1 (C-1) and Client #2 (C-2).
  • Per Facility Administrator, all staff and clients are fully vaccinated (including all boosters).
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. There is an additional freezer with food supply.
  • PPE supplies observed. Additional supplies are stored inside the office.
  • Hygiene supplies observed. Additional supplies are stored inside the hallway closet.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Clients socially distance according to local public health guidelines and wear masks.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Brenda Seaborn.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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