<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601973
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:49:45 PM


Document Has Been Signed on 07/12/2022 12:49 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: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: 6DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Amanda Palomino, AdministratorTIME COMPLETED:
01:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA arrived unannounced and met Licensees/Administrators, Amanda Palomino and Boris Palomino. The facility is licensed for residents ages 60 and over and approved for 5 non-ambulatory and 1 bedridden.

LPA toured the facility and observed the following:
* 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.
* The swimming pool at the premises has a 6 foot fence surrounding the pool and is locked.
* COVID-19 signage are posted throughout the facility.
* The facility screens and logs the temperature of visitors.
* Beds are moved at least 6 feet apart in shared bedrooms.
* Staff were wearing face masks.
* Knives and disinfectants are locked and inaccessible to clients.
* Food supplies of 2 day perishable and a week of non-perishable were observed.
* PPE supplies of at least 30 days are in storage.
* Emergency numbers and clients' information are up-to-date.
* LPA reviewed all 6 clients' medication and compared to the MAR log. They are all given as prescribed.
Per licensee, they are continuing to follow the mitigation plan and testing weekly. They continue to clean and disinfect daily and more often for high touched surfaces.

LPA provided Technical Assistance on the N95 Respirator Fit Testing.

There are no citations issued today. An exit interview was held and a copy of this report was given to the
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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 1