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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602208
Report Date: 07/14/2023
Date Signed: 07/14/2023 12:47:38 PM

Document Has Been Signed on 07/14/2023 12:47 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:
07/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Mirna Alderete, CaregiverTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA met with Assistant Administrator, Jose Alderete, who assisted with the inspection. The annual inspection was first initiated on 7/6/23. LPA continued with the remaining domains listed below today.

Staffing: There is sufficient staffing at the facility. There is an awake staff for the overnight shift. The Administrator's certificate for Travis Holland expires on 7/31/23. Staff are fingerprint cleared and associated to the facility.
Personnel Records-Training: LPA reviewed 3 staff files. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff have on-going training.
Client Rights-Information: Client rights are posted and included in Client files. There are no clients using postural supports.
Client Records-Incident Reports: LPA reviewed all 3 Client files. The files include the Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent For Medical Treatment, Individual Program Plan/IPP, Client Rights, and Property Valuable forms.
Health Related Services: The medications are centrally stored and locked. LPA reviewed medication for all 3 Clients. Staff documents on the Medication Administration Record (MAR) log when given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: There are no clients with a restricted health condition plan.
Disaster Preparedness: The facility has the Emergency Disaster Plan with emergency procedures noted.

There are no deficiencies issued today. A technical assistance was provided. An exit interview was held and a copy of this report was given to Jose Alderete.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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