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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603020
Report Date: 01/30/2024
Date Signed: 01/31/2024 09:14:38 AM

Document Has Been Signed on 01/31/2024 09:14 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:FMJVITACARE1 CORPFACILITY NUMBER:
198603020
ADMINISTRATOR:ALICE REYESFACILITY TYPE:
735
ADDRESS:2718 BLAKEMAN AVETELEPHONE:
(909) 641-7109
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 4DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ann Fernandez TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted an annual required visit. LPA met with House Manager Ann Fernandez and explained the reason for the visit. Ms. Fernandez assisted with today's visit.

The facility is a single story house and is located in a residential neighborhood area. The following was reviewed : kitchen, dining area, living room, 4 clients bedrooms, 2 clients bathrooms and attached garage. The laundry area is in the garage. All 4 client bedrooms were toured. Each bedroom has the required furniture and bed linen, sufficient lighting and closet space. Both bathrooms were toured and were clean, sanitary and in good working condition. The hot water temperature measured 117.8 degrees F in bathroom #1 and 120 degrees F in bathroom #2. LPA observed a sufficient amount of perishable and non-perishable food supply. All the appliances are clean and working properly. 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 has a shaded area and sitting area for clients to utilize. LPA also inspected the smoke detectors and carbon monoxide detectors, which are operable. Sharp objects are kept in a kitchen cabinet and are inaccessible to the clients. The cleaning supplies are locked in a cabinet in the garage and are inaccessible to clients.

LPA reviewed 4 clients files and 2 staff files, which contain the required documents. Client medication was also reviewed, and LPA observed it is being administered as prescribed. Most recent fire drill was conducted on 1/23/24.

No deficiencies were observed during the visit. Exit interview conducted and a copy of the report was provided to the Ms. Fernandez.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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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