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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603021
Report Date: 02/13/2024
Date Signed: 02/13/2024 02:59:07 PM


Document Has Been Signed on 02/13/2024 02:59 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:FAMILY HOME LLCFACILITY NUMBER:
198603021
ADMINISTRATOR:VILLALVA, JOEL HFACILITY TYPE:
740
ADDRESS:1629 CALLE CIERVOTELEPHONE:
(626) 354-0265
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 4DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Joel Villalva- AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Joel Villalva, and explained the purpose for the visit.

During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (4) resident medications, (4) resident files, (3) staff files, and conducted interviews with (2) staff, and attempted interviews with (4) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents, of which (1) may be bedridden. It has an approved Dementia Care Plan and a Hospice Waiver approved for (2) residents. There are currently no residents receiving hospice care. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file, as required.

LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats. The hot water was tested and measured at 111*F, which is in compliance. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted on 01/14/2024. Auditory devices were observed at all entrances/exits of the home and were operational. (4) resident files and (3) staff files were reviewed and observed to be complete with all required documentation. (4) resident medications were reviewed and were observed to be documented properly and given as prescribed.

No deficiencies were observed or cited, during today's visit.
An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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