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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602208
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:37:47 AM

Document Has Been Signed on 05/31/2024 11:37 AM - 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/
DIRECTOR:		HOLLAND, TRAVISFACILITY TYPE:
735
ADDRESS:462 E GROVE STTELEPHONE:
(909) 398-4488
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 3CENSUS: 3DATE:
05/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Kelvin Torrent, DSPTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA met with Administrator, Jose Alderete, who assisted with the visit. The initial inspection was conducted on 5/23/24.

LPA continued the remainder of the domains from the CARE tool and the following was observed:
Client Rights-Information: Client rights are posted. There are no clients using postural supports. Facility provides internet service.
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 in the closet by the entrance. LPA reviewed medication for all 3 Clients and are being administered as prescribed.
Incidental Medical Services: There are no clients with a restricted or prohibited health condition.
Disaster Preparedness: The facility has the updated Emergency Disaster Plan with emergency procedures and relocation sites.

No deficiencies issued today. 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: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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