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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602531
Report Date: 08/19/2022
Date Signed: 08/19/2022 12:38:22 PM

Document Has Been Signed on 08/19/2022 12:38 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:CALVITACARE1 CORPFACILITY NUMBER:
198602531
ADMINISTRATOR:MYRABEL VITANGCOLFACILITY TYPE:
735
ADDRESS:3037 EAST MERRYGROVE STREETTELEPHONE:
(626) 612-7318
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Milagros Fransisco, DSPTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Milagros Fransisco and explained the purpose of the visit. Administrator Myrabel Vitangcol was explained the purpose of today's visit telephonically. There are four (4) level 4C ambulatory developmentally disabled clients ages 18-59 in the home. The facility is a single story home located in a residential neighborhood that is licensed for 4 ambulatory only clients. It consists of 4 client bedrooms, office room, living room, dining room, kitchen, 2 bathrooms, backyard patio area, and attached garage. The last fire drill was conducted on June 28, 2022. Administrator certificate expires 8/27/2022.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • Four (4) client centrally stored resident medication records were reviewed. Medications are documented properly and given as prescribed.
  • Staff were observed wearing mask. Clients wear masks in the home, except when in their private room and during meal times.
  • The kitchen was inspected and a sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • A posted Emergency Disaster Plan was observed.
  • Facility has at least a 30-day supply of Personal Protective Equipment (PPEs).
  • All staff have fingerprint clearances. Staff and resident files were not reviewed during today's visit.


Per California Code of Regulations, Title 22, there were NO deficiencies observed during the visit.

Exit interview was conducted with staff Milagros Fransisco. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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