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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602123
Report Date: 11/19/2021
Date Signed: 11/19/2021 12:39:10 PM

Document Has Been Signed on 11/19/2021 12:39 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 CAMERONFACILITY NUMBER:
198602123
ADMINISTRATOR:PACIO, MARIAFACILITY TYPE:
735
ADDRESS:2441 CAMERON AVETELEPHONE:
(626) 732-3500
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 2DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:S1, Staff in charge
S2, caregiver		TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA was allowed entry and met with Staff #1 (S1). Both Staff #1 and Staff #2 (S2) assisted with visit. The facility is licensed to serve four (4) non-ambulatory Developmentally Disabled clients who are age 18-59. Current client census is two (2). None of the clients has a Restricted Health Condition. Two (2) clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center. Annual licensing fees are current. LPA discussed the purpose of today's visit.


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

The facility is a single-family home located in a residential neighborhood and consist of three (3) client bedrooms, two (2) bathrooms, living room, kitchen, den, dining area and laundry area. Back yard activity area is a shaded area with chairs and free of debris/ hazard.

Bathrooms are clean and operable. Adequate linen and personal hygiene supply are in stock. Dual Smoke/Carbon monoxide detectors are tested and operable. First aid kit is fully stocked with manual. Hot water temperature measured at 116.8 degrees Fahrenheit. The last Fire/ Emergency Drill was conducted on Nov 12, 2021. Delayed egress and audio device are working.

Sufficient supply of perishable and non-perishable foods. Medications are centrally stored, locked and the records are current. Medication that requires refrigeration are locked and stored inside the refrigerator.

Hazardous items are locked and inaccessible to clients. Fire extinguishers’ last service is on 11/3/2021 which is located in the kitchen. (-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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: PEOPLE'S CARE CAMERON
FACILITY NUMBER: 198602123
VISIT DATE: 11/19/2021
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Administrator certificate is current and expires on 5/19/2022. Comfortable temperature of 73 degrees Fahrenheit for clients was maintained.

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

Exit conference is conducted. LIC 809 is discussed and provided to facility staff.

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

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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