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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601526
Report Date: 05/03/2022
Date Signed: 05/03/2022 12:05:15 PM

Document Has Been Signed on 05/03/2022 12:05 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:JULSTIN RESIDENTIAL CARE CENTERFACILITY NUMBER:
198601526
ADMINISTRATOR:OMAR SAPALARANFACILITY TYPE:
735
ADDRESS:2318 E. WALNUT CREEK PKWYTELEPHONE:
(626) 862-7207
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Perry Williams TIME COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with DSP Perry Williams and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA's 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 was approved on 06/29/21. The facility is a vendorized with San Gabriel Pomona Regional Center and LICENSED FOR 4 NON-AMBULATORY AGES 18 THROUGH 59.

The facility is a single story house and located in a residential neighborhood. The facility included living room#1 and #2, dining area, kitchen, four clients bedrooms, one client bathroom, one staff bathroom, laundry room and a detached garage. All four clients bedrooms were toured. Each bedroom has one bed, one drawer, one chair, required furniture and linen and sufficient lighting and closet space. The two bathrooms are clean, sanitary and operational. The hot water temperature in two bathrooms were measured between 105 and 106.4 degrees F which is within the Title 22 regulation. The food supply are stored in the kitchen and garage are sufficient for two days perishable and seven days non-perishable. All appliances are clean and working properly. All the knives and sharp utensils are locked in the kitchen cabinet. All the toxic and cleaning supplies are locked in the laundry room and garage which are inaccessible to clients. The common are such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and the back yard has a shaded area with tables and chairs which are available for client to use. Yard is free of debris. Exits and passageways are free of obstructions. LPA also inspected the carbon monoxide detectors and smoke detectors and they are interconnected and they are operational.


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SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: JULSTIN RESIDENTIAL CARE CENTER
FACILITY NUMBER: 198601526
VISIT DATE: 05/03/2022
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On today's inspection, LPA also reviewed four clients files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screening and fingerprint clearances and all are updated. LPA reviewed all four clients' medications. The medications are centrally stored and locked in the cabinet near the kitchen and the clients' medications seemed accurate and updated and the record is current.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each room and facility is disinfected every shift, bathrooms have sufficient soap, paper towels, and signs, the PPE supplies are sufficient for 30 days.

No deficiencies were observed during the visit.

Exit interview conducted. A copy of the report was provided to DSP Perry Williams.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
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