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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602936
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:04:22 PM

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:MY LADIES GUEST HOUSEFACILITY NUMBER:
198602936
ADMINISTRATOR:TILLMAN, GREGFACILITY TYPE:
740
ADDRESS:128 N FOURTH STREETTELEPHONE:
(626) 863-6349
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:15CENSUS: 8DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Greg Tillman, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the infection control domain. LPA arrived unannounced and met with the Administrator, Greg Tillman. The purpose of the visit was explained. The facility is approved for 15 residents, ages 60 and over, of which 15 may be non-ambulatory. The current census at the home is 8.

This facility has a total of 10 bedrooms and 7 bathrooms downstairs. Rooms #1 - #6 are either single or shared rooms and Rooms #7 - #10 are all single bedrooms with a private bathroom. Residents do not have access to the upstairs space which is the Administrator's office.

LPA toured the facility inside and out with the Administrator. The following were inspected/observed:
* Signage are posted by the front entrance and throughout the facility in regards to hand washing, cough etiquette, and the Coronavirus (Covid-19).
* The facility has one entry point for all visitors. Table is set up by the entrance where the visitor's log and temperature are documented. Masks and hand sanitizers are readily available.
* There is a designated room to isolate individual who is tested positive for covid-19. This room has a private bathroom which is located toward the back of the house.
* Extra supplies of PPE such as N95 masks, hand sanitizers, and gowns were stored in the garage.
* Disinfectant and cleaning supplies are stored and locked under the kitchen sink and storage space by room #6.
* Bathrooms are stocked with soap and paper towels.
* Medications for 4 individuals were reviewed and are being administered as prescribed by the physician.
* There are adequate food supplies of 2 day perishable and a week of non-perishable observed.

There are no deficiencies observed during the visit today. An exit interview was conducted and a copy of this report along with appeal rights were provided to the Co-Administrator.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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