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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601822
Report Date: 04/22/2024
Date Signed: 04/22/2024 11:37:13 AM

Document Has Been Signed on 04/22/2024 11:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SPECIALIZED RESIDENTIAL MONTELLANOFACILITY NUMBER:
198601822
ADMINISTRATOR/
DIRECTOR:		DONOVAN COVINGTONFACILITY TYPE:
735
ADDRESS:2767 MONTELLANO AVETELEPHONE:
(626) 961-2824
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 4DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Administrator Donovan Covington TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with Administrator Donovan Covington and the purpose of the visit was discussed. The following tool domains were completed:

Infection Control: LPA observed the facility has sufficient PPE supplies. Infection Control Plan is in place. The plan was collected and reviewed.

Physical Plant and Environmental Safety: The facility is licensed to serve 4 developmentally disabled adults ages 18 to 59 years old, of which (4) can be non-ambulatory. There are currently 4 clients who were placed by the San Gabriel Pomona Regional Center. Facility is located in a residential area and consist of a living room, kitchen, dining area, attached garage/laundry area, (4) client bedrooms, (1) and a half bathrooms, office area and an office. The facility was inspected during the physical plant tour. No passageways or paths were obstructed.

Operational Requirements: Facility is operating within its approved clearance.

Staffing: The facility has a sufficient staffing in the facility. Facility is present during the Nightshift.

Personnel Records-Training: Personal records centrally stored. LPA inspected four (4) staff files. All staff are background check cleared and associated with the facility. All the staff files have the required Title 22 documents. The administrators certificate is currently pending renewal.

Client's Right - Information: No client in the facility required any postural support at the present time. Required postings observed.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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: 04/22/2024
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Food Service: Supply of Non perishables and perishables was observed. Food supply was adequately stored. Pesticides and other toxic substances were not stored with the food supply. Kitchen area was clean.

Client Records/Incident Reports: Client files are centrally stored. LPA reviewed four (4) client files. Client files are up to date and have required documents.

Health Related Services: Medication is centrally stored and locked making them inaccessible to clients in care. LPA reviewed four (4) Client Medications. LPA did not observe any medication mismanagement.

Incidental Medical Services: No client in the facility has any restricted health condition plan. There are no clients in care with prohibited or restricted health conditions. First Aid kid observed and available when needed.

Disaster preparedness: The facility has an updated emergency disaster plan. The last fire/disaster drill was conducted on 4/15/24. Facility has client information readily available in case of emergencies.

Emergency Intervention: The facility are not using any restraints in the facility.

Per Title 22 Regulations, no deficiencies are being cited on todays visit.

Exit Interview conducted. A copy of the report was provided
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
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