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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602123
Report Date: 11/30/2023
Date Signed: 12/01/2023 01:17:40 PM

Document Has Been Signed on 12/01/2023 01:17 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:MARGIE KIMBLEFACILITY TYPE:
735
ADDRESS:2441 CAMERON AVETELEPHONE:
(626) 732-3500
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 2DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Margie Kimble TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced annual inspection visit. LPA met with Administrator Margie Kimble, who assisted with visit. Facility is licensed to serve four (4) non-ambulatory Developmentally Disabled clients who are age 18-59.

During the visit, the Inspection tool was used, staff and clients were interviewed, a tour of the facility was conducted, and the following were reviewed : food supply, medications, and staff and resident files.



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. 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 degrees Fahrenheit. The last Fire/ Emergency Drill was conducted on 11/12/23. Sufficient supply of perishable and non-perishable foods are observed. Medications are centrally stored, locked and the records are current. Hazardous items are locked and inaccessible to clients. Fire extinguishers is fully charged and located in the kitchen. Copy of surety bond was observed.

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

Exit interview was conducted, and a copy of report was provided to administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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