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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601822
Report Date: 03/30/2023
Date Signed: 03/30/2023 01:41:26 PM

Document Has Been Signed on 03/30/2023 01:41 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:DONOVAN COVINGTONFACILITY TYPE:
735
ADDRESS:2767 MONTELLANO AVETELEPHONE:
(626) 961-2824
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 3DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Donovan Covington (Administrator)TIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Kruz Long and Erik Zaragoza conducted a site visit for the annual inspection. Upon arriving at the facility, LPAs met with Donovan Covington (Administrator) and explained the purpose of the visit. The facility is licensed to serve 4 NON-AMBULATORY CLIENTS AGES 18-59.

LPAs utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Infection Control, Physical Plant & Environment Safety, Operational Requirements, Staffing, Personnel Reports-Training, Client Rights - Information, Client Records-Incident Report, Food Services, Health Related Services, Incidental Medical Services, Disaster Preparedness, Emergency Intervention.

A tour of the single story facility includes: Living room, kitchen, dining area, attached garage/laundry area, 4 client bedrooms, 1 and a half bathrooms, office area and an office.

During today’s visit, LPAs observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked in the kitchen drawer. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. Lamps or lights in all rooms to ensure the comfort and safety were observed. Hot water temperature measured at 112.3 degrees F in the full bathroom. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. A plan to ensure that clients receive assistance in meeting their medical and dental needs were observed. Continue to LIC809C.....
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 03/30/2023
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All staff have a criminal record clearance. Initial Needs and Services Plan is updated. Each client record contains the Needs and Service Plan and a Mental Health Intake Assessment. Staff responsible for direct care and supervision have current first aid. Clients list of their Personal Rights were observed. LPAs were allowed to enter the facility to conduct the inspection. The Administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Donovan Covington.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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