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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601815
Report Date: 04/12/2022
Date Signed: 04/12/2022 02:51:18 PM

Document Has Been Signed on 04/12/2022 02:51 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:ALFORD HOMEFACILITY NUMBER:
198601815
ADMINISTRATOR:SEAN ESTRELLAFACILITY TYPE:
734
ADDRESS:165 ALFORD STTELEPHONE:
(909) 599-7403
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 5CENSUS: 3DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Sean EstrellaTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Sean Estrella and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records, observed food supply, and reviewed staff records. The facility cares for adults with special health care needs and is vendorized by San Gabriel/Pomona Regional Center.

All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The lift system was operating properly in each bedroom and bathroom. The client bathroom also has the required grab bars and non-skid materials. The hot water was 106.8 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food and g-tube formula for clients. All the appliances are clean and seem to be operating properly. The common areas include the front and back living room and dining area. These areas are clean and have the required furniture. There is a screening station at the entrance of the home which has PPEs and a thermometer to screen visitors. Staff document client temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs. Visitation is allowed in bedrooms, common areas and outside patio.

LPA reviewed 3 client records to confirm emergency contact is updated and physician's reports are on file. Staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 3 clients' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided to Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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