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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601666
Report Date: 09/09/2022
Date Signed: 09/12/2022 11:24:20 AM

Document Has Been Signed on 09/12/2022 11:24 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:SPECIALIZED RESIDENTIAL MAVERICK CIRCLEFACILITY NUMBER:
198601666
ADMINISTRATOR:AGUILA, AGNESFACILITY TYPE:
735
ADDRESS:1 MAVERICK CIRTELEPHONE:
(909) 629-2453
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 4DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Agnes Aguila, AdministratorTIME COMPLETED:
12:45 PM
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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 Agnes Aguila (Administrator) and explained the purpose of today's visit.

This home consists of (4) bedrooms, 2 full-bathrooms, kitchen, dinning area, living room, laundry room, office and an attached garage.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, in all common rooms and hallways.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • All Clients have their own private bedroom.
  • Per Administrator, (4) clients have both vaccines and booster.
  • Per Administrator, (13) staff have have both vaccines and booster.
  • Medication reviewed for (4) Clients (Client #1 through Client #4).
  • PPE supplies observed.
  • Hygiene supplies observed.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Clients were socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Agnes Aguila
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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