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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601492
Report Date: 01/21/2022
Date Signed: 01/21/2022 11:12:32 AM

Document Has Been Signed on 01/21/2022 11:12 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:BEGINNINGSFACILITY NUMBER:
198601492
ADMINISTRATOR:HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:1112 BASELINE RDTELEPHONE:
(909) 305-0250
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 3CENSUS: 2DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:S-1TIME 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 met with S-1 and explained the purpose of today's visit.

This home consists of (3) private client bedrooms, (2) bathrooms, living room, kitchen, dinning area, laundry set-up is inside the attached garage. LPA toured grounds. All Clients residing at this facility 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 at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed.
  • Hygiene supplies observed.
  • Restrooms have hand soap and hand sanitizer.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • C-1 and C-2 are fully vaccinated. Booster pending/to be determined.
  • There are (7) staff working at this facility. (3) out of (7) are fully vaccinated and have the booster. (4) out of the (7) have exemptions and are tested weekly.
  • Medication reviewed for (2) Clients (Client #1 and Client #2).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-2
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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