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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602964
Report Date: 06/06/2022
Date Signed: 06/06/2022 04:29:41 PM

Document Has Been Signed on 06/06/2022 04:29 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:PACIFIC HORIZONFACILITY NUMBER:
198602964
ADMINISTRATOR:KIM, MICHAELFACILITY TYPE:
735
ADDRESS:9115 UNION STTELEPHONE:
(562) 368-1479
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 6CENSUS: 4DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Mylene BumanlagTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jose Villalobos made an unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Mylene Bumanlag. The purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (4) client records, (3) staff files, and (4) client medications. Currently the facility has (4) clients of which (4) are ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. Facility is a one story family home with Four (4) bedrooms. Bedroom #1-#4 are for one (1) client each. There are (2) bathrooms for client use. There is also a living room, a kitchen, central air and heating, a dining area, a shaded area in the frontyard. An attached car garage inaccessible to clients. Front and back yard is in good condition at time of visit. Backyard has a shed for storage and separate building for live in staff. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. All bedrooms equipped with required furniture for clients. Bathroom #1 is private for bedroom #1 and has a working toilet, wash basin, and shower. Bathroom #2 has a working toilet, wash basin, and shower Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations. Last Fire drill on 5/9/22.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and a copy of this report was provided to Administrator Mylene Bumanlag
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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