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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601730
Report Date: 09/24/2021
Date Signed: 09/24/2021 12:47:07 PM

Document Has Been Signed on 09/24/2021 12:47 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:CAPS ALZHEIMER'S DAY SERVICESFACILITY NUMBER:
198601730
ADMINISTRATOR:VATCHE KELARTINIANFACILITY TYPE:
775
ADDRESS:2501 E CORTEZ ST,N WING #14-16TELEPHONE:
(626) 917-4484
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 30CENSUS: 8DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Dolores Llamas Lopez (Activity Aide)TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced Annual Inspection at the facility.
Upon arrival, LPA met with Dolores Llamas Lopez (Activity Aide) and explained the purpose of the visit. The Adult Day Program is approved to serve ambulatory adults ages 18 and older.

A tour of the facility consist the following: Activity room, Kitchen/Dining area, Arts and Crafts room, Office and 2 restrooms. LPA observed that the licensee is not operating the adult day program beyond the conditions and limitations specified on the license, including the capacity limitation. All clients are protected against hazards. There are no pools and bodies of water on the premises. Disinfectants, cleaning solutions, poisons are locked under the sink inaccessible to clients. Hot water temperature measured between 105 degrees F and 120 degrees F in the restroom. All toilets, hand washing and bathing facilities is maintained in a safe, sanitary, operating condition. Clients in care for less than 8 hours is provided meals and snacks. The licensee provides care and supervision necessary to meet the client's needs and all services. The facility is kept clean and dry and free of odors. Program personnel is sufficient and competent to provide the services necessary to meet individual client needs. All individuals subject to a criminal record review has clearance or an exemption. Disaster drills was conducted and documented at least every 6 months. First aid kit is lock and stored in the dining area.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Dolores Llamas Lopez.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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