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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601507
Report Date: 06/29/2022
Date Signed: 06/29/2022 11:47:13 AM

Document Has Been Signed on 06/29/2022 11:47 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:LOST RIVER HOMEFACILITY NUMBER:
198601507
ADMINISTRATOR:NAVEEN REDDYFACILITY TYPE:
735
ADDRESS:21625 LOST RIVER DR.TELEPHONE:
(909) 510-9314
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 4CENSUS: 4DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Naveen ReddyTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Naveen Reddy and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records, staff records and observed the food supply. The facility cares for adults with intellectual disabilities and is vendorized by San Gabriel/Pomona Regional Center as a Level 4G facility.

All client bedrooms were toured. All bedrooms are private rooms and have the required bed, bedframe, linen, dresser, light, and closet space. Both client bathrooms were toured and the hot water was 107.3 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. All chemicals are locked in a cabinet in the garage. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. There is a second refrigerator in the garage. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs stored in the staff office. There are no cameras inside or outside the facility. There is a screening station with PPEs at the entrance of the facility. Staff document client temperatures and symptoms daily as required.

Client files were reviewed to confirm emergency contacts and individual program plans are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. All files were complete. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, 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: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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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