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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602624
Report Date: 05/27/2022
Date Signed: 05/27/2022 12:46:21 PM

Document Has Been Signed on 05/27/2022 12:46 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:SWEET HOLLANDER HOMEFACILITY NUMBER:
198602624
ADMINISTRATOR:ARQUERO, LORNAFACILITY TYPE:
735
ADDRESS:3074 HOLLANDER STTELEPHONE:
(909) 445-0021
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 6DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Facility Administator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Facility Administrator and explained the purpose of today's visit.

This home consists of 4 bedrooms, 2 bathrooms, living room, kitchen, and dinning area. All clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed.
  • Hygiene supplies observed.
  • Incontinence supplies observed/stored inside the attached garage.
  • Restrooms have hand soap, hand sanitizer and paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Per Administrator, all (6) clients are fully vaccinated including the 1st booster vaccine.
  • Per Administrator, all staff are fully vaccinated including the 1st booster.
  • Medication reviewed for (6) Clients (Client #1 through Client #6).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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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