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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602017
Report Date: 10/23/2023
Date Signed: 10/23/2023 11:59:12 AM

Document Has Been Signed on 10/23/2023 11:59 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:PALACIOS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198602017
ADMINISTRATOR:PALACIOS, RAQUELFACILITY TYPE:
735
ADDRESS:1232 MILLBURY AVETELEPHONE:
(626) 338-0854
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 6CENSUS: 5DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Raquel PalaciosTIME COMPLETED:
12:15 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
On 10/23/23 at 9:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Palacios Adult Residential Facility. Upon arrival LPA was greeted by the Administrator, Raquel Palacios. This home is licensed to serve adults ages 18 through 59, (6) ambulatory of which (3) maybe non-ambulatory, residents to reside in room #3 and #4 only. The is vendored through San Gabriel Pomona Regional Center. There were (0) clients in care during the time of this visit, the (6) clients were at the day program or an outing. The last emergency disaster/fire drill was conducted on 5/06/23. The Administrator Certificate expires on 6/22/2024 #6017970735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (2) staff files, (5) client files, medications, and medication administration records for (5) clients and P&I.

This home contains 4 bedrooms, 2 staff bedrooms, 2 bathrooms, living room, sitting room, kitchen, dining room, gated pool, and an attached garage. LPA toured the physical plant with the Administrator, and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, shower with grab bar, and shower chair. The temperature measured at 116.4*F-119.3*F respectively. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was located in sitting room, tested, and functioning properly. There were (1) fire extinguishers located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The knives were secured and locked in kitchen cabinet. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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 2
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: PALACIOS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198602017
VISIT DATE: 10/23/2023
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
26
27
28
29
30
31
32
The outdoor grounds were toured and inspected, and the patio was well maintained with a gated pool. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The sitting room contained board games and activity supplies available to the clients.

Exit interview conducted with Raquel Palacios, Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2