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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601973
Report Date: 08/01/2023
Date Signed: 08/01/2023 12:24:15 PM


Document Has Been Signed on 08/01/2023 12:24 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
GREATER LA AC/SC, 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:
08/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Amanda Palomino - AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Amanda Palomino Administrator an explained the reason for the visit.

The facility is licensed for residents ages 60 and over and approved for 5 non-ambulatory and 1 bedridden. The facility is a one story home located in a residential area and has 3 bedrooms, 3 bathrooms, living room, kitchen, dining room, family room, laundry area, and an attached garage.

LPA Flores conducted a tour with administrator and observed the following:
Facility is clean and in good repair inside and outside. Living room has a cover fireplace. Kitchen is clean and knives and cleaning supplies are kept in lock cabinets. Refrigerator and freezer were observed at 40 degrees and 0 degrees which are within the recommended temperatures. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Family room has a fireplace with decoy decorations and dining room has sufficient seating space. Each bedroom has the required furniture, bedding, and sufficient lighting. 3 bathrooms were observed in working condition with grab bars and skid mats. Water temperature was tested in each, and tested between 115.2-118.2 degrees F., which is within the required 105-120 degrees F. Smoke/Carbon Monoxide detectors were observed and tested throughout the facility. A pool was observed with a 5ft fence around it., and shaded seating area was observed in the backyard. Fire extinguishers were last checked on 6/21/23. Facility conducted an evacuation drill on 6/1/23. Emergency food supplies and water were observed. Emergency disaster plan and Infection control plan were reviewed.

LPA reviewed medication and files for 5 residents and 5 staff files, and conducted interviews with 2 staff and 2 residents. Administrator certificate was observed for Amanda Palomino #60312667440 exp date 6/15/24.

No deficiencies were noted during this visit per Title 22 Regulations.
Exit interview was conducted with administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
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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