198602551-1-31-2025-28-AS-NGAA-DDFPMF-20250131102617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602551
Report Date: 01/31/2025
Date Signed: 01/31/2025 10:26:24 AM

Document Has Been Signed on 01/31/2025 10:26 AM - 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 LIVING		FACILITY NUMBER:	198602551
ADMINISTRATOR/ DIRECTOR:	KISS, ADRIANA REY		FACILITY TYPE:	740
ADDRESS:	8743 YOUNGDALE STREET		TELEPHONE:	(626) 731-3244
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/31/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:01 AM
MET WITH:	Adriana Kiss, Administrator		TIME VISIT/ INSPECTION COMPLETED:	10:30 AM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to Administrator Adriana Kiss. The facility is licensed to care for elderly residents ages 60 and older. The facility is a single story home located in a residential neighborhood consisting of 3 resident bedrooms, 2 staff bedrooms, living room, dining room, kitchen, laundry room, 3 bathrooms, backyard patio area, detached garage, and a building/ ADU (Additional Dwelling Unit) in the rear of the property. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Twelve (12) CARE tools domains were reviewed.

The following were observed/inspected:

Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: A Dementia and hospice waiver for 1 resident, and a fire clearance for 6 non-ambulatory residents, of which one (1) may be bedridden in room 1 is in place. Facility does not handle resident P & I monies; therefore a Surety Bond is not in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is not active because there has not been any residents since Dec. 2022.

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. Cleaning supplies and toxic substances are inaccessible to residents. The facility has fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The last Emergency Disaster drill was conducted on 1/2/2025.

Staffing: The facility is licensee operated. Licensee is the only staff at this time due to zero census.

Lisa Hicks	TELEPHONE: (323) 981-3972
Noemi Galarza	TELEPHONE: (323) 981-3974
	DATE: 01/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOME AWAY ASSISTED LIVING	FACILITY NUMBER: 198602551
	VISIT DATE: 01/31/2025

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Personnel Records/Staff Training: Administrator certificate expires 5/10/2026. Staff has criminal background clearance and training. Only Licensee/Administrator file was reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training us current.

Resident Records/Incident Reports: The facility currently is not caring for any residents. Licensee wishes to remain licensed.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.

Incident Medical and Dental: Not applicable due to zero census.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: There are currently no residents residing at the facility.

A Technical Advisory was issued advising that an updated facility sketch shall be submitted to reflect the rear ADU.

No health and safety concerns were observed. No deficiencies were observed.

An exit interview was conducted with Administrator Adriana Kiss. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC809 (FAS) - (06/04)

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