<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603035
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:55:41 PM

Document Has Been Signed on 10/17/2023 04:55 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:
10/17/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Melissa VasquezTIME COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Wong conducted an Annual/Required visit by using the Compliance And Regulatory Enforcement (CARE) Tools on 10/13/23 but due to time restrains and LPA Christine Wong has returned on today's date 10/17/23 to finish the remaining five (5) domains. LPA met with staff Garrett Harbin who allowed entry into the facility and also assisted with LPA's visit today.

On today's date, LPA inspected the five (5) domains include: Staffing, Personnel Records-Training, Client Records-Incident reports, Disaster Preparedness and Emergency Intervention.

1.Staffing: The facility has sufficient staffing in the facility. LPA reviewed the NOC shift staff and they have the required training for facility planned emergency procedure.

2. Personnel Records-Training: All the staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. The administrator of the facility is Melissa Vasquez and she has all the requirement or prior experience to become an administrator of the facility. Her administrator expiration date: 5/31/24. She does have the updated HIV and TB training certificate. All the staff files have the required documents in their files which is included updated health screening, TB test result, required training hours and updated first aid certificate.

3. Client Records-Incident reports: LPA reviewed all four (4) clients files and they all have the required documents include the updated monthly individual behavioral support plan, face sheet, physician report, TB test result, ambulatory status, individual program plan (IPP), pre placement, admission agreement, medication list.

(See LIC 809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 10/17/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
4. Disaster Preparedness: The facility has an emergency disaster plan in place but not updated. The last fire and disaster drill was conducted on 5/21/23. The facility has two alternative shelter location.

5. Emergency Intervention Plan: The facility would use restraint for the last resources and all staff has an updated CPI training hours.

No deficiencies were observed during the visit.

Exit Interview conducted and a copy of the report was provided to Staff Garrett Harbin.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2