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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602551
Report Date: 11/29/2022
Date Signed: 11/29/2022 04:04:03 PM


Document Has Been Signed on 11/29/2022 04:04 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: 1DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Zoltan Kiss, Assistant Administrator TIME COMPLETED:
04:05 PM
NARRATIVE
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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 staff Nelia Romero and explained the purpose of the visit. Assistant Administrator Zoltan Kiss arrived shortly after and was explained the purpose of the visit. There is one (1) resident 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. The last fire drill was conducted on 10/2/2022. Administrator certificate expires 5/10/2024.

OBSERVATIONS
  • The facility consists of 3 resident bedrooms, 2 staff bedrooms, living room, dining room, kitchen, laundry room, 3 bathrooms, backyard patio area, detached garage, and an ADU (Additional Dwelling Unit) in the rear of the property.
  • COVID-19 Infection Control signs were observed in the entrance, common areas, hallways, and bathrooms. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. A visitor screening station is in the entry. It includes a thermometer, hand sanitizer, masks, and gloves. Personal Protective Equipment (PPE's) was observed.
  • The residents do not wear a face mask due to cognitive impairment.
  • The private room has been designated as a COVID-19 isolation room if needed.
  • One (1) month supply of centrally stored medications was observed.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • Criminal Background Clearance was checked.

No deficiencies were observed.

Exit interview was conducted with Assistant Administrator Zoltan Kiss. A copy of the report was provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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