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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601663
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:00:16 AM

Document Has Been Signed on 09/19/2024 11:00 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:SAPPHIRE GEM HOME CAREFACILITY NUMBER:
198601663
ADMINISTRATOR/
DIRECTOR:		SAMONTE, MICHELLE TORRESFACILITY TYPE:
735
ADDRESS:326 E LA VERNE AVETELEPHONE:
(909) 623-0728
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 4DATE:
09/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Nora Rodriguez/S-1TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management visit pertaining to an alleged incident involving Client #1 (C-1) and Staff #2 (S-2) which occurred on 09/07/24 (alleged sexual abuse). LPA was allowed entry by Staff #1 (S-1). LPA discussed the purpose of today's visit.

During this visit, LPA reviewed files for C-1 and S-2 and obtained relevant documentation. LPA obtained contact information for the Quality Assurance (Q/A) representative from San Gabriel Pomona Regional Center. LPA also conducted a tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats.

LPA interviewed S-1. LPA attempted to interview C-1 (C-1 refused to be interviewed). LPA interviewed Q/A representative from San Gabriel Pomona Regional Center via telephone.

Exit interview conducted and a copy of this report was provided to S-1.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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