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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601666
Report Date: 09/15/2023
Date Signed: 09/15/2023 11:13:30 AM

Document Has Been Signed on 09/15/2023 11:13 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: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:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Agnes AguilaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Agnes Aguila and discussed the purpose of today’s visit.

This home consists of (4) bedrooms, 2 full-bathrooms, kitchen, dining area, living room, laundry room, office and an attached garage. This home has fire clearance for (2) non-ambulatory and (2) ambulatory clients. All clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: Last Disaster Drill was conducted on 08/16/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Carbon monoxide detector was tested and is operable. Fire extinguishers were observed (1) in the kitchen, (1) in the hallway and (1) in the laundry room (last serviced: 03/24/23). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured as follows: 106.0*
***Refer to LIC 809C for the continuation of this report***.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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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: SPECIALIZED RESIDENTIAL MAVERICK CIRCLE
FACILITY NUMBER: 198601666
VISIT DATE: 09/15/2023
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Staffing: There is sufficient staffing at the facility. Administrator Certificate on file for Agnes Aguila expires 03/03/25. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at this location. LPA reviewed staff files for Staff #1 (S-1) and Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Client Rights-Information: Client rights are posted and included in Client files. There are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, Individual Program Plan, House Rules, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored inside the refrigerator. Facility has emergency food supply stored inside the garage. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and are mostly bubbled packed. LPA reviewed medication for C-1 through C-4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: There are clients with a restricted health condition plan. Facility has restricted health condition plan in place.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place.

Exit interview, appeals rights and a copy of this report was provided to Agnes Aguila.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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