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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603035
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:52:12 PM

Document Has Been Signed on 04/18/2024 02:52 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:PUENTE HOMEFACILITY NUMBER:
198603035
ADMINISTRATOR/
DIRECTOR:		MELISSA VAZQUEZFACILITY TYPE:
737
ADDRESS:1423 E PUENTE AVETELEPHONE:
(626) 331-6331
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Melissa Vazquez TIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced case management visit to the facility to ascertain information pertaining to the request of the facility infection control plan. LPA met with Administrator Melissa Vazquez who allowed the entry to the facility and assisted with the visit.

On 03/27/24, LPA Wong contacted the administrator and requested the facility infection control plan and administrator stated that they are going to provide by Monday 4/1/24. On 4/2/24 (Tuesday), Licensing Program Manager (LPM) David Sicairos contacted the administrator via email to inquire about the facility infection control plan but no response. LPM also contacted the facility number at 909-596-5360 and 909-260-1232 since 4/2/24 but did not get any call back from anyone. On 4/10/24, LPM sent another email to the administrator about the facility infection control plan and the licensee Robert Subia called back and spoke to LPM and stated that they would send the infection control plan by the end of the business day (4/10/24). As of today 4/18/24, LPA and LPM did not receive any facility infection control plan from the facility.

According to the California Code of Regulations (Title 22, Division 6, Chapter 6), LPA observed the following deficiencies and issued a citation.

An exit interview was conducted and a copy of the Report and Appeal Rights were provided to Administrator Melissa Vazquez.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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Document Has Been Signed on 04/18/2024 02:52 PM - It Cannot Be Edited


Created By: Christine Wong On 04/18/2024 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PUENTE HOME
FACILITY NUMBER: 198603035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
85095.5(c)

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85095.5 Infection Control Plan (c)An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.

The requirement was not met as evidenced by:
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The facility administrator will send the copy of the infection control plan to LPA by POC due date.
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Record review, LPA did not receive the facility Infection Control Plan in place which the facility supposed to have the infection control plan since 2022.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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