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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602931
Report Date: 10/06/2021
Date Signed: 10/25/2021 08:06:41 AM

Document Has Been Signed on 10/25/2021 08:06 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:JOSHUA TREE HOMEFACILITY NUMBER:
198602931
ADMINISTRATOR:JASMIN TOMINESFACILITY TYPE:
735
ADDRESS:18207 VILLA CLARA STREETTELEPHONE:
(626) 295-2197
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 6DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH: Jasmin Tomines (Administrator)TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Jasmin Tomines (Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 18 through 59. 6 ambulatory, of which 2 may be non-ambulatory.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, attached garage/storage/laundry area, kitchen, dining area, office, staff room, 2 bathrooms and 4 client bedrooms.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. The licensee has ensured that each client has clean linen in good repair. There are no pools and bodies of water on the premises. No firearms are on the premises and other dangerous weapons such as knives and sharp objects are locked. A comfortable temperature for clients is maintained at all times. Hot water temperature measured at 114.5 degrees F in bathroom #1. The licensee has ensure provisions for clients such as feminine napkins, non-medicated soap, toilet paper, toothbrush, toothpaste, and comb. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days was observed. The licensee employs staff as necessary to ensure provision of care and supervision to meet client needs. Staff have a criminal record clearance. Staff responsible for direct care and supervision have current first aid. Employees of CCLD is allowed to enter the facility to conduct inspections. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. All medications shall be labeled and maintained in compliance with label instructions and State and Federal law. Medications is safe, locked and inaccessible.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to Jasmin Tomines.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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