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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602208
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:33:06 PM

Document Has Been Signed on 07/06/2023 04:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELEANOR RICHARDSON HOMEFACILITY NUMBER:
198602208
ADMINISTRATOR:HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:462 E GROVE STTELEPHONE:
(909) 398-4488
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 3CENSUS: 3DATE:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mirna Alderete, CaregiverTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Staff, Mirna Alderete. The purpose of the visit was explained. Administrator, Jose Alderete, arrived shortly thereafter to assist with the visit. The facility is licensed for (3) adults, ages 18 - 59, and of which (1) may be non-ambulatory.

LPA toured the facility and conducted the following domains during the visit today:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves when necessary. Staff are continuing to clean and disinfect during each shift and more often for high touched surfaces. Facility has sufficient PPE supplies.
Physical Plant & Environment Safety: The facility does not have any swimming pool or bodies of water on the premises. There are 3 client bedrooms, 1 administrator's office, 2 bathrooms, living room, dining area, kitchen, and an attached garage. Each client bedroom has the required furniture and bedding. Extra hygiene supplies and linens are observed. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to clients. There are no firearms or weapons stored at the facility.
Operational Requirements: The facility is operating within the approved fire clearance. There are 3 ambulatory clients residing at the home. Staff are providing the care and supervision as necessary to meet the clients' needs.
Food Service: There are sufficient food supplies of 2 day perishable and a week of non-perishable. The kitchen is clean and free of pests.

LPA will return to complete the remainder of the domains on a later date. An exit interview was conducted and a copy of this report was given to Administrator Alderete.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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