<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601526
Report Date: 05/23/2024
Date Signed: 05/23/2024 11:19:38 AM

Document Has Been Signed on 05/23/2024 11:19 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:JULSTIN RESIDENTIAL CARE CENTERFACILITY NUMBER:
198601526
ADMINISTRATOR/
DIRECTOR:		OMAR SAPALARANFACILITY TYPE:
735
ADDRESS:2318 E. WALNUT CREEK PKWYTELEPHONE:
(626) 862-7207
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Omar SapalaranTIME VISIT/
INSPECTION COMPLETED:
11:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Wong conducted the required annual inspection. LPA arrived unannounced and met with DSP Perry Williams who allowed the entry of the facility and explained the reason of the visit and shortly after Administrator Omar Sapalaran Arrived and assisted with the visit. The facility is licensed for four non-ambulatory age 18-59. The facility is vendorized as Level 4C home with San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and here are the domains that LPA inspected:

1. Infection Control: The facility has an updated infection control plan in place. The facility continues to practice hand washing and disinfect the facility every shift. The facility also has sufficient PPE supplies.

2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes kitchen, dining area, living room, four clients bedrooms, two clients bathrooms, laundry room and a detached garage and a storage room. Each client's room has one bed, one drawer, one chair, required furniture and beddings, and sufficient lighting and closet space. The two client's bathrooms are clean, sanitary and in a good working condition. The hot water temperature in two client's bathrooms are tested between 119.4 and 120 degrees F which is within the Title 22 regulation. All the appliances in the kitchen are working properly. The sharp knives and utensils are stored in the kitchen drawer next to the stove. All the cleaning supplies and chemicals are stored and locked in the garage. The facility has a telephone on the premises. The hallway night will be on during night time so client can have access to the non-private bathrooms. The extra personal hygiene products are stored in the garage. LPA inspected the carbon monoxide detectors and smoke detectors are interconnected and they are working well.
3. Operational Requirement: The facility are licensed for 4 non-ambulatory clients age 18 through 59 and currently the facility only has one client is non-ambulatory which is within the fire clearance. The facility would allow client to attend community events if there's an opportunity or a chance. The facility has a shaded area with table and chairs in the backyard for client to utilize the outdoor activity. The last fire drill was conducted on 4/2/24
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: JULSTIN RESIDENTIAL CARE CENTER
FACILITY NUMBER: 198601526
VISIT DATE: 05/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
4. Staffing: Facility has sufficient staffing for the care and supervision of the clients. The facility has at least one person on call on the premises. The NOC shift staff has a facility emergency procedure training in file.

5. Personnel Records-Training: All the staff files are stored in the storage room next to the garage. LPA inspected three staff files and All three staff are over 18 years old, fingerprint cleared and associated with the facility. All the staff have the required documents include: health screening , TB Test result, required training hours and First Aid Certificate. The administrator Omar Sapalaran and administrator certificate expire on 6/2/25 and has the updated HIV and TB training certificate.

6. Client's Right: The facility has no client with any postural support. The facility has internet service and provide at least one internet access device such as computer and equipped with video conferencing that client can communicate with their primary physician and family if needed.

7. Food Service: The facility has two days perishable and seven days non perishable food supply. All the food are stored properly in the facility. No client in the facility required any modified diet that prescribed with the doctor.

8. Client Records-Incident Reports: All the client's file are stored and locked in the file cabinet in the living room. All the clients files have the required documents which include: face sheet, admission agreement, functional capability assessment, Individual Program Plan (IPP), medication list, ambulatory status, physician and dental report.

9.Health Related Services: The facility would assist client with medical and dental appointments. All the client's medication are centrally stored and locked in the kitchen cabinet next to the refrigerator. LPA inspected all four clients' medication and they all seemed accurate and updated and all clients have the 30 days supply of medication. All the staff have the required medication training hours. LPA inspected the first aid kit and it stored and locked in the hallway cabinet and it has all the required supplies.

10. Incident Medical Services: Currently the facility has no client with restricted health condition plan or any client with prohibited health condition.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: JULSTIN RESIDENTIAL CARE CENTER
FACILITY NUMBER: 198601526
VISIT DATE: 05/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
11. Disaster Preparedness: The facility has an updated emergency disaster plan and dated on 5/20/23. The facility has two alternative shelter location. The Emergency Disaster Plan is posted on the wall with contact numbers. Emergency procedures are indicated on the form.

12. Emergency Intervention: The facility does not use any restraints on clients and all staff have the updated Pro-Act Training in file.

No deficiencies were observed during the visit.

Exit Interview conducted and a copy of the report was provided to the administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3