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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602551
Report Date: 01/19/2022
Date Signed: 02/10/2022 02:30:12 PM

Document Has Been Signed on 02/10/2022 02:30 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:HOME AWAY ASSISTED LIVINGFACILITY NUMBER:
198602551
ADMINISTRATOR:KISS, ADRIANA REYFACILITY TYPE:
740
ADDRESS:8743 YOUNGDALE STREETTELEPHONE:
(626) 731-3244
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 6CENSUS: 2DATE:
01/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:Adriana Kiss, AdministratorTIME COMPLETED:
04:50 PM
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DUPLICATE REPORT- Due to technical issues the original document did not record properly.
Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Alvaro Navarro and explained the purpose of the visit. Administrator Adriana Kiss arrived shortly after and was explained the purpose of the visit. There are two (2) residents over the age of 60. The facility is a single story home located in a residential neighborhood that is licensed for 6 non- ambulatory residents, of which 1 may be bedridden. A hospice waiver for 1 and Dementia waiver is in place. It consists of 3 resident bedrooms, 2 staff bedrooms, living room, dining room, kitchen, laundry room, 3 bathrooms, backyard patio area, and detached garage. The last fire drill was conducted on 1/12/2022. Administrator certificate expires 5/10/2022.

The following were observed/inspected:
· The interior and exterior physical plant was inspected.
· Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical
distancing. Facility has an approved COVID-19 mitigation plan.
· COVID-19 Infection Control signs were observed in the entrance, common areas, hallways, and bathrooms.
LPA was screened upon entry by staff.
· Each resident room has been designated as a COVID-19 solation room if needed.
· Two (2) centrally stored resident medication records was reviewed.
· Residents in care do not wear masks because it is not tolerated due to cognitive impairment.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
· A posted Emergency Disaster Plan was observed.
· Sufficient supply of Personal Protective Equipment (PPEs) was observed.
· Staff and resident files were not reviewed during today's visit.
No deficiencies were cited.
Exit interview was conducted with Administrator Adriana Kiss. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
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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