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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602031
Report Date: 06/16/2023
Date Signed: 06/16/2023 12:23:51 PM

Document Has Been Signed on 06/16/2023 12:23 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:TOTAL LIFE CARE, INC - EVOLVE SERVICESFACILITY NUMBER:
198602031
ADMINISTRATOR:MONTESINOS, JESSICAFACILITY TYPE:
775
ADDRESS:545 EREMLAND DRIVETELEPHONE:
(626) 257-3235
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 60CENSUS: 22DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jessica Montesinos, Program Director and
Nilesh Makwana, Program Assistant Director		TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Jessica Montessinos, Program Director, and Nilesh Makwana, Program Assistant Director, who assisted with visit. The facility is a day program and licensed to serve sixty (60) Developmentally Disabled of which fifty (50) ambulatory and ten (10) non-ambulatory clients. Facility licensing fees are current. There are currently 22 clients at the facility during the visit and total of 30 clients on roster. Total of 27 clients received case management services provided by San Gabriel/ Pomona regional center and 2 clients received services from FDLRC and 1 client received services from IRC.

During the visit, Care Tool was used, a tour of the facility was conducted and staff/clients files were reviewed. Facility does not provide daily snacks or meals at the day program.

LPA observed the facility is a single story building located in a commercial business area. The facility consisted of a Reception area with Case Manager office space, a Janitorial room, Chef room (Client's kitchen), Staff Lounge, Canvas room, Pulse room/ Computer Lab, Staff kitchen, Laundry room, Serenity (Relaxation) room, Einstein room, Core room, Basics room, Evolve room, Media room, Program Directors office, Behavioral Consultant office, Conference room, Human Resource office, four (4) restrooms, and a shaded area with chairs provided in the rear and indoor/ outdoor activity areas. Water temperature in the bathroom is measured at 116.5 degrees Fahrenheit and toilets observed operable. Medications are centrally stored, locked and maintained in the Media room. Medication records are current. Facility smoke detectors and carbon monoxide devices are operable, fire extinguishers’ last service date is 01/09/23, disaster drill is conducted on 05/18/23, first aid kit is fully stocked with all required items, cleaning supplies and other toxins are locked in a storage room. All rooms have required furniture and equipment necessary to conduct all activities.

(-continued LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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: TOTAL LIFE CARE, INC - EVOLVE SERVICES
FACILITY NUMBER: 198602031
VISIT DATE: 06/16/2023
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All clients bring their own lunch, however, facility has back-up food and snacks. Snack is stored, prepared, and served in a safe and healthful manner. Facility has plenty of water available for clients. Hazardous items are inaccessible to clients.

No deficiencies were cited per Title 22 during this visit. Exit interview was conducted with Program assistant director, Neilesh and a copy of this report was provided
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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