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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602531
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:59:30 PM

Document Has Been Signed on 08/29/2024 03:59 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/
DIRECTOR:		MYRABEL VITANGCOLFACILITY TYPE:
735
ADDRESS:3037 EAST MERRYGROVE STREETTELEPHONE:
(626) 612-7318
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:26 PM
MET WITH:Milagros Franciso, Lead StaffTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced Required - 1 year annual inspection visit. The purpose of the visit was explained telephonically to Administrator Myrabel Vitangcol. DSP Milagros Francisco assisted with the visit. The facility serves developmentally disabled residents under age 59. The facility is licensed as a level 4C Adult Residential Facility (ARF) vendored by San Gabriel/Pomona Regional Center. The facility is a single story home located in a residential neighborhood that is licensed for 4 ambulatory only clients. It consists of 4 resident bedrooms, office room, living room, dining room, kitchen, 2 bathrooms, backyard patio area, and attached garage. The following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility has an Infection Control Plan in place.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fully charged fire extinguisher. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

Operational Requirements: Fire clearance is approved for four (4) ambulatory only residents. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. Facility has a Surety Bond.



Staffing: A total of seven (7) staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Five (5) staff files were reviewed. Criminal background clearance, in-service training, CPI training, 1st Aid/CPR training, and health screening.

Administrator certificate expired 8/27/2024. Administrator provided proof that recertification application was submitted to DSS Certification Unit, and is presently pending processing.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CORP
FACILITY NUMBER: 198602531
VISIT DATE: 08/29/2024
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Resident Rights/Information: Resident Personal Rights poster is posted in the office room. Internet access is available for residents. Physician's orders are on file. One (1) resident requires a modified die. HCBS Rights are posted in the office room.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I records. Files have been updated with HCBS Tenant/Landlord Rights and Responsibilities Agreement.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were reviewed.

Incident Medical and Dental: Files have Needs and Services Plan and updated medical assessments, and COVID-19 vaccination cards on file. Staff training was reviewed.

Disaster Preparedness, and Emergency Intervention: LIC 610D "Emergency Disaster Plan/Disaster and Mass Casualty Plan" is current.

The last Fire/Emergency Drill was conducted on 6/14/2024, within 6 months of Title 22 requirement.

Emergency Intervention: Facility uses CPI de-escalation and crisis reduction techniques. Staff training is current.

No deficiencies cited.



Exit interview was conducted with Lead DSP Milagros Franciso. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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