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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602869
Report Date: 03/01/2022
Date Signed: 03/01/2022 10:56:55 AM

Document Has Been Signed on 03/01/2022 10:56 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:JJVITACARE1, INCFACILITY NUMBER:
198602869
ADMINISTRATOR:VITANGCOL, MYRABELFACILITY TYPE:
735
ADDRESS:21321 FOUNTAIN SPRINGS ROADTELEPHONE:
(909) 641-7109
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 5DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Florentino VitangcolTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Florentino Vitangcol and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records, inspected food supply, and reviewed staff records. The facility cares for developmentally disable adults and is vendorized by San Gabriel/Pomona Regional Center as a Level 4 home.

All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The client bathrooms have the required grabs bars and non-skid mat for non-ambulatory clients. The hot water was 108.4 degrees which is within the required 105 - 120 degrees. Cleaning supplies are locked in the garage and inaccessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. There is additional food in the garage freezer. All the appliances are clean and seem to be operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. The entrance of the home has sanitizer, PPEs and a thermometer. Staff document client temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs.

LPA reviewed 5 client records to confirm emergency contact is updated and clients have health screenings on file. 4 staff records were reviewed to confirm health screenings, infection control training and fingerprint clearances. LPA reviewed 5 clients' medications. Medications are documented properly and are locked in a cabinet making them inaccessible to clients.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided to Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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