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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601975
Report Date: 10/18/2021
Date Signed: 10/18/2021 01:10:25 PM

Document Has Been Signed on 10/18/2021 01:10 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:C & N GROUP CORPORATIONFACILITY NUMBER:
198601975
ADMINISTRATOR:CHRISTOPHER SORTOFACILITY TYPE:
735
ADDRESS:1249 N ARMELTELEPHONE:
(626) 498-0409
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 5DATE:
10/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Eliazar Medina, Staff TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve six (6) Non-Ambulatory clients, (age 18-59). Client census is five (5). LPA was allowed entry by the facility staff. Administrator, Christopher Sorto joined the visit telephonically. San Gabriel Pomona Regional Center provides case management service to client residing in this home. LPA discussed the purpose of today's visit.

During the visit, the following domain of the new inspection tool was used: infection control domain;
a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

LPA met with staff who assisted with the visit. LPA toured the facility inside and outside. The home is located in a residential neighborhood within the city of Covina and is a one story house which consists of a living room, attached garage/storage, dining area, kitchen, three (3) client bedrooms and two (2) bathrooms.

The kitchen was clean and had maintained the required two (2) days perishable and seven (7) days non- perishable. All burners and stove tops were in working condition. Clients’ bedrooms had beds, dressers, chairs and closet space available. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. Adequate linen and personal hygiene supply were observed. Resident beds were in good condition and had appropriate linens. Bathrooms were clean and operational.

LPA also inspected facility common areas including the kitchen, living room, and dining room. Dual detectors which combined with a Smoke Detector and carbon monoxide detector were operational. Last fire drill was conducted on 9/30/2021. Fire extinguisher was fully charged. The first aid kit was fully stocked with a manual. There are no firearms on the premises and other dangerous weapons such as knives are locked in the kitchen cabinet. Comfortable temperature for clients was maintained. Hot water temperature measured at 110.5 degrees Fahrenheit. (-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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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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: C & N GROUP CORPORATION
FACILITY NUMBER: 198601975
VISIT DATE: 10/18/2021
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Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

Medications were centrally stored and locked in a cabinet. Medications were properly logged and current. Hazardous items were locked and inaccessible to clients.

No deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to facility Staff, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC809 (FAS) - (06/04)
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