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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602019
Report Date: 06/22/2023
Date Signed: 06/22/2023 01:26:54 PM

Document Has Been Signed on 06/22/2023 01:26 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:PEOPLE'S CARE COVINA HILLSFACILITY NUMBER:
198602019
ADMINISTRATOR:RAMOS, JOLLIEREY (JOLLIE)FACILITY TYPE:
735
ADDRESS:1412 E COVINA HILLS RDTELEPHONE:
(626) 498-0075
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 3DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Staff#1TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tao conducted an annual required visit. LPA met with staff#1, who assisted with a tour of the physical plant. The facility is licensed to serve four (4) Developmentally Disabled Non-Ambulatory clients, (age 18-59). Facility is approved for delayed egress and secured perimeters. All clients residing at this home receive case management services provided by San Gabriel / Pomona Regional Center. Annual licensing fees are current. LPA explained the reason for the visit.

This annual visit consisted of: CARE tool was used, a tour of the facility was conducted, food supply was reviewed, staff/client files were reviewed, staff/client interviews were conducted, and medications were reviewed. Facility has submitted a mitigation plan and was approved.

The facility is a single house located in a residential neighborhood. The facility consisted of four (4) bedrooms, two (2) bathrooms, living room, dining room, kitchen, conference/meeting room, laundry room, office area, storage closets, garage and an indoor/outdoor activity area. A shaded area with chairs is provided in the back yard. The yard is free of debris/ hazard, and there are covered trash cans. Bathrooms are clean and in working condition. Sufficient supply of perishable and non-perishable foods are observed. Adequate linen and personal hygiene supply are observed. Smoke detectors are monitored by a fire protection company and its last service was on 3/23/23. Carbon monoxide detectors are tested and in working condition. The first aid kit is fully stocked. Hot water temperature measured at 108.5 degrees Fahrenheit.
(-continued in LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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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: PEOPLE'S CARE COVINA HILLS
FACILITY NUMBER: 198602019
VISIT DATE: 06/22/2023
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The last fire/ emergency drill is conducted on 06/01/23. Delayed egress/ exits are tested and operable. Medications are centrally stored and locked. Hazardous items are locked and inaccessible to clients.

No citations were being cited per California Code of Regulation Title 22, Division 6, Chapter 1.

Exit interview was conducted with Staff#1 and report LIC 809s were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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