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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603035
Report Date: 11/08/2022
Date Signed: 11/08/2022 04:04:59 PM

Document Has Been Signed on 11/08/2022 04:04 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:PUENTE HOMEFACILITY NUMBER:
198603035
ADMINISTRATOR:YASHICA MORROWFACILITY TYPE:
737
ADDRESS:1423 E PUENTE AVETELEPHONE:
(909) 596-5360
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Angela Synder TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Christine Wong and Program Clinical Consultant Toni Rivera conducted an unannounced annual required visit. LPA met with Assistant Administrator Angela Synder 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, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood. The facility includes : kitchen, dining area, living room, four clients bedrooms, two bathrooms, common area/activity area, office and attached garage. All 4 clients bedrooms were toured. Each bedroom has a one bed, one chair, one night stand, required furniture and bed linen, sufficient lighting and closet space. All 2 bathrooms were toured. They are clean, sanitary and in a good working condition. The hot water was tested between 109.4 and 111.3 degrees F which is within the Tittle 22 regulation. The refrigerator in the kitchen and garage has sufficient 2 days perishable and 7 days non-perishable food supply. All the kitchen appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The back yard has a shaded area and sitting area. The sharp utensils and sharp knives are stored and locked on top of the medication cart.

LPA reviewed 4 client files to confirm emergency contact and they are all updated. LPA also reviewed 2 staff files to confirm health screenings and fingerprint clearance and they are all updated. Clients also has 30 days supply of medication and incontinent supplies.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, facility is disinfected every few hours, the bathrooms have sufficient soap, paper towels, and signs, and PPE supplies are sufficient for 30 days.

Exit Interview conducted and a copy of the report was provided to Assistant Administrator Angela Synder.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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