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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602422
Report Date: 10/03/2023
Date Signed: 10/03/2023 12:49:30 PM

Document Has Been Signed on 10/03/2023 12:49 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:PEOPLE'S CARE VIOLAFACILITY NUMBER:
198602422
ADMINISTRATOR:HUENDY MORAFACILITY TYPE:
737
ADDRESS:1605 VIOLA PLTELEPHONE:
(909) 671-4184
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 3CENSUS: 3DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Chris Rodriguez, Lead SupervisorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection. LPA arrived unannounced and met with Lead Supervisor, Chris Rodriguez. The purpose of the visit was explained. Administrator, Huendy Mora, arrived shortly after and assisted with the visit. The facility is licensed for (3) adults, ages 18 - 59, of which 3 may be non-ambulatory.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility.
The facility consists of 3 client bedrooms, 1 staff office, 1 small storage room, 2 bathrooms, living room, dining room, kitchen, laundry room, and garage. The spacious backyard has a shaded area with chairs and table. 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.
Facility staff are using appropriate hand hygiene and wearing gloves when necessary. Staff are continuing to clean and disinfect high touched surfaces. Facility has sufficient PPE supplies. 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. There are sufficient food supplies of 2 day perishable and a week of non-perishable, plus emergency supplies. The kitchen is clean and free of pests.
There is sufficient staffing at the facility. Overnight staff are awake and monitoring clients individually. The Administrator's certificate expires on 10/26/23. Staff are fingerprint cleared and associated to the facility. LPA reviewed 4 staff files. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are receiving on-going training. 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. 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.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: PEOPLE'S CARE VIOLA
FACILITY NUMBER: 198602422
VISIT DATE: 10/03/2023
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client(s) with a restricted health conditions have their plan in file. Staff receiving training for each client in regard to their restricted health condition. 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 administrator Mora.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
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