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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601973
Report Date: 08/19/2021
Date Signed: 08/19/2021 11:24:25 AM

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:PALOMINO RESIDENTIAL CAREFACILITY NUMBER:
198601973
ADMINISTRATOR:AMANDA PALOMINOFACILITY TYPE:
740
ADDRESS:1400 PIEDRA WAYTELEPHONE:
(323) 353-1167
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY:6CENSUS: 5DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Amanda Palomino, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced annual visit using the Infection Control Evaluation domain. LPA met with Licensees/Administrators Amanda Palomino and Boris Palomino and explained the reason for the visit. The facility is approved for 5 non-ambulatory and 1 bedridden residents, ages 60 and over. There are currently 5 residents residing at the home.

The licensees provided a tour of the facility inside and out. The following were observed/inspected:
· Upon entry, temperature was taken and recorded on a log.
· The facility has 3 bedrooms, 3 bathrooms, living room, kitchen, dining room, family room, laundry area, and an attached garage. Each bedroom is equipped with the required furnishings.
· Bathrooms have soap, paper towels, and trash bins with lids.
· There are no items obstructing the entry or walkway.
· Signage for Covid-19 are posted around the facility to promote hand hygiene and cough etiquette.
· A pool is located in the backyard, surrounded by a 6 foot fence and is locked.
· Staff at facility were all wearing face coverings and were assisting residents with their activities.
· Knives and disinfectants were all stored and locked, inaccessible to residents.
· Medications were reviewed for all 5 residents and are being administered as prescribed by the physicians.
· Sufficient food supplies of 2-day perishable and a week of non-perishable are observed.
· The hot water temperature was measured at 117.7 degree F, which is within the required range of 105 – 120 degree F.

There are no deficiencies observed during today’s visit. A copy of this report along with the appeal rights were given to the Licensee.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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