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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602570
Report Date: 10/13/2022
Date Signed: 11/01/2022 12:54:08 PM

Document Has Been Signed on 11/01/2022 12:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JRC PLATINUM CARE HOMEFACILITY NUMBER:
198602570
ADMINISTRATOR:CANONES, JUNELLEFACILITY TYPE:
735
ADDRESS:2929 VAMANA STREETTELEPHONE:
(909) 279-5485
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Rizalina Gaetos/S-1TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Annual visit. LPA was allowed entry into this home by Rizalina Gaetos/S-1. LPA discussed the purpose of today's visit

This home consists of 4 bedrooms, 2 bathrooms, living room. kitchen and dinning room. San Gabriel Pomona Regional Center provides case management services to all (4) clients residing at this facility.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Hygiene and incontinence supplies observed. Additional supplies stored inside the garage.
  • PPE supplies observed. Additional supplies stored inside the garage.
  • Restrooms have hand soap, hand sanitizer and paper towels. Hand washing signs were observed inside both bathrooms. (1) bathroom is located in the hallway and the other is located between bedroom #2 and bedroom #4 (Jack and Jill bathroom).
  • Medication reviewed for (4) Clients (Client #1 through Client #4). Each client has a designated locker for their medication and files which remain locked at all times.
  • Per S-1, all (4) clients are fully vaccinated including the 1st booster vaccine.
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Rizalina Gaetos/S-1
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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