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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601419
Report Date: 06/08/2022
Date Signed: 06/09/2022 08:23:15 AM

Document Has Been Signed on 06/09/2022 08:23 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EMPSON ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601419
ADMINISTRATOR:SANDRA M. EMPSONFACILITY TYPE:
735
ADDRESS:655 SOUTH EASTBURY AVETELEPHONE:
(626) 858-2701
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 6CENSUS: 3DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Sandra Empson TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christine Wong and Benette Pena conducted an annual required visit. LPAs met with Licensee administrator Sandra Empson and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files. Facility has submitted a mitigation plan and approved on 5/7/21.

The facility is a single story house and located in a residential neighborhood area. The facility includes, three clients bedroom, one client bathroom, licensee and husband bedroom and bathroom, living room, kitchen, den, laundry room and a detached garage. All 3 client bedrooms were toured. Bedroom#1 has one bed, one dresser, one night stand, required furniture and linen and sufficient closet space and lighting. Bedroom#2 and #3 has two beds, two drawers, required furniture and linen and sufficient closet space and lighting. Client's bathroom was toured. The bathroom is clean, sanitary and in working condition. The hot water temperature in bathrooms and kitchen was tested between 118.2 and 120 degrees which is within Title 22 regulation. The refrigerator in the kitchen and garage has sufficient for two days perishable and 7 days non-perishable food storage. All the kitchen appliances are clean and working properly. The knives and sharp utensils are locked in the kitchen cabinet and inaccessible to clients. The common areas such as living room and dining area are clean and have the required furniture. The toxic and cleaning supplies are stored in the locked cabinet in the laundry room and is inaccessible to clients. The front and back yard are maintained well and back yard has a shaded area with table and chairs.

LPA's reviewed 3 client files to confirm emergency contact is updated. LPA also reviewed two staff files and they are all fingerprint cleared and updated health screening on file. LPA reviewed 3 clients' medications and all 3 clients medication are updated and seemed accurate.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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: EMPSON ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601419
VISIT DATE: 06/08/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in the common area and facility is disinfected the whole day, restrooms have sufficient soap, paper towels, and signs, PPE supplies is sufficient for more than 30 days.

No deficiencies cited per California Code of Regulations, Title 22, Division 6.

Exit interview was conducted, a copy of this report was provided to Facility Licensee/Administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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