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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603012
Report Date: 02/09/2023
Date Signed: 02/09/2023 04:35:59 PM


Document Has Been Signed on 02/09/2023 04:35 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:INSPIRED ELDERLY CARE LIVINGFACILITY NUMBER:
198603012
ADMINISTRATOR:GALLEGOS, LAURIEFACILITY TYPE:
740
ADDRESS:1438 E PORTNER STREETTELEPHONE:
(909) 240-1321
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Laurie Gallegos TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with Administrator/Licensee Laurie Gallegos and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes living room, kitchen, guest bathroom, caregiver/live in staff bedroom, caregiver bathroom/laundry room, four residents bedrooms, one resident bathroom and an attached garage. All 4 resident bedrooms were toured. Bedroom#1 and #4 has two beds, two chairs, two dressers, required furniture and bed linen and sufficient closet space and lighting. Bedroom#2 and #3 has one bed, one chair, one dresser, one night stand, require furniture and bed linen and sufficient closet space and lighting. The resident bathroom was toured and bathroom has the required grabs bars and non-skid mat. The hot water temperature was tested at 117.3 which is within the Title 22 regulation. The refrigerator in the kitchen and the kitchen cabinet has sufficient for 2 days perishable and 7 days non-perishable food supply. All the appliances in the kitchen are clean and working properly. The sharp knives and utensils are stored and locked in the kitchen cabinet and inaccessible to residents All the chemical and cleaning supplies are stored in the garage and they are all inaccessible to resident. The common areas such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and the back yard have the shaded area with tables and chairs for resident to utilize. The smoke detectors and carbon monoxide are interconnected and they are working probably.

LPA reviewed all 6 resident files to confirm emergency contact are updated. LPA also reviewed 2 staff files to confirm health screenings and fingerprint clearances and they are all fingerprint cleared and has the updated health screening in their personnel file. LPA also reviewed 6 residents medication and they are all centrally stored and locked in the cabinet next to the dining area and all seemed accurate and updated, and records are current.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSPIRED ELDERLY CARE LIVING
FACILITY NUMBER: 198603012
VISIT DATE: 02/09/2023
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, facility is disinfected every 2 hours. The resident bathroom have sufficient soap, paper towels, and signs and the PPE supplies are sufficient for more than 30 days.

No deficiencies were observed during the visit.

Exit interview conducted and a copy of the report was provided to the administrator Laurie Gallegos
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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