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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601822
Report Date: 04/07/2022
Date Signed: 04/07/2022 04:02:18 PM

Document Has Been Signed on 04/07/2022 04:02 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:SPECIALIZED RESIDENTIAL MONTELLANOFACILITY NUMBER:
198601822
ADMINISTRATOR:CUA-KIM, JANEFACILITY TYPE:
735
ADDRESS:2767 MONTELLANO AVETELEPHONE:
(626) 961-2824
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 3DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Angela WilliamsTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with House Manger Donovan Covington and explained the reason for the visit and he also assisted LPA with the visit. Shortly after, the administrator Angela Williams arrived. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients files. Facility has submitted a mitigation plan and was approved on 06/14/2021

The facility is a single story house and located in a residential neighborhood area. The facility included a living room, dining area, kitchen, four clients rooms, two clients bathrooms, staff office, medication cabinet, storage cabinet and an attached garage. All 4 clients bedrooms were toured. Each bedroom has a smoke detector, one bed, one chair, one dresser, one night stand, required linen, sufficient lighting and closet space. All 2 bathrooms were toured and they are clean and sanitary. The hot water was measured at two bathrooms are between 115.3 and 116.8 degrees F which is within Title 22 regulation. The food supply in the refrigerator, kitchen cabinet and garage is sufficient for two days perishable and seven days non-perishable. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and the back yard has a shaded area with tables and chairs for client to utilize. The cleaning supplies are stored in the garage cabinet and it is inaccessible to clients. The knives and utensils are locked and stored in the kitchen cabinet. The medication are centrally stored and locked in the medication cabinet. LPA also reviewed all clients medications and they are all accurate and current. And all clients' emergency contact information are up-to dated. LPA also inspected the smoke detectors and carbon monoxide detectors and they are interconnected and working properly.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in the common area and facility is disinfected every shift.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MONTELLANO
FACILITY NUMBER: 198601822
VISIT DATE: 04/07/2022
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The client's bathrooms have sufficient soap, paper towels, and signs and, and PPE supplies are sufficient for more than 30 days.

No deficiencies were found during the visit.

Exit Interview held. A copy of the report was provided to the administrator Angela Williams.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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