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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603035
Report Date: 10/13/2023
Date Signed: 10/13/2023 04:41:20 PM

Document Has Been Signed on 10/13/2023 04:41 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:MELISSA VAZQUEZFACILITY TYPE:
737
ADDRESS:1423 E PUENTE AVETELEPHONE:
(909) 596-5360
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Melissa VasquezTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Melissa Vazquez allowed the entry of the facility and assisted with the visit. The purpose for the visit was explained. The facility is licensed for Age Range 18 through 59. 4 ambulatory which 3 maybe non-ambulatory. Non-ambulatory in bedrooms 1,2 &3. The facility is vendored as an Enhanced Behavioral Support Home (EBSH) with San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and only inspected those domain:

1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan.

2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room#1, Living room#2, dining area, kitchen, open staff office, four clients bedrooms, two clients bathrooms and an attached garage. Each client bedroom has one bed, one chair, one drawer, one night stand, required furniture and beddings and sufficient lighting and closet space. The two client bathrooms are clean, sanitary and in a good working condition. The hot water in two client bathroom were tested between 112.2. and 113.9 degrees F. which is within Title 22 regulation. All the knives and sharp utensils are stored and locked in the medication cart. All the cleaning supplies and chemicals are stored and locked in the cabinet near the living room#1. The extra personal hygiene products are stored and locked in the cabinet in the garage. The extra linen and towels are stored in the cabinet near the living room#1. The facility would turn on the hallway light for client to access the non-private bathrooms at night. The facility has a land-line telephone system. LPA inspected the carbon monoxide detectors and smoke detectors and they are interconnected and they are working properly. The walkway, passageway and patio are free of obstruction.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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: PUENTE HOME
FACILITY NUMBER: 198603035
VISIT DATE: 10/13/2023
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3. Operational Requirement: The fire clearance is approved for 1 ambulatory and 3 non-ambulatory. Currently all clients are ambulatory. Facility does have a Enhanced Behavioral Support Home folder in place. The last fire and disaster drill was conducted on 5/21/23. The facility has a patio with a shaded area with table and chairs for client to utilize for outdoor activity. Surety Bond is also in place. The facility handles client's monies.

4.Client's right-Information: Currently the facility does not have any postural support clients. The facility does serve adults with internet service with at least one internet access device that they can support with real time interactive application like face time with their family or zoom meeting with their day program.

5. Food service: Currently no client is on modified diet that prescribed by a physician. The clients are only on calorie control diet. The facility has sufficient in the facility is with restricted health condition plan or prohibited health condition.

6. Incidental Medical Services: Currently the facility has no client with prohibited health condition and one (1)client is currently on restricted health condition plan. All the documents are updated and included in client's files which included the restricted health condition plan signed by the doctor and reviewed by the regional center.

7.Health Related Services: The client's medication are stored and locked in the medication cart. LPA inspected all four (4) clients medication and they are seemed updated and accurate and they all have 30 days supply of mediation. Facility staff would provide transportation for client's medical and dental appointment.

Due to time restraints, LPA will come back another time to inspect the other domains which include: Staffing, Personnel Records-Training, Client Records-Incident reports, Disaster Preparedness and Emergency Intervention.

No deficiencies were observed during the visit.

An exit interview conducted and a copy of the report was provided to Administrator Melissa Vazquez.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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