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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603045
Report Date: 01/13/2023
Date Signed: 01/20/2023 08:02:09 AM

Document Has Been Signed on 01/20/2023 08:02 AM - 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:WHITE ROSE GUEST HOMEFACILITY NUMBER:
198603045
ADMINISTRATOR:CLAUDIA CONTRERASFACILITY TYPE:
735
ADDRESS:19161 ALDORA DRTELEPHONE:
(626) 581-8358
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 3DATE:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Francine Campana TIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with Administrator Francine Campana 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, reviewed observed food supply, and reviewed resident files and staff files

The facility is a single story house and located in the residential neighborhood area. The facility includes kitchen, dining room, family room, four clients bedrooms, two clients bathrooms and attached garage. All 4 clients bedrooms were toured. Each bedroom has one bed, one night stand, one drawer, required furniture, bed linen and sufficient lighting and closet space. All 2 bathrooms were toured and they were clean, sanitary and in a good working condition. The hot water temperature in the kitchen and bathroom were tested between 112.6 and 106.7 which is within Title 22 regulation. The refrigerator in the kitchen and garage has sufficient two days perishable food and the kitchen cabinet has sufficient for seven days non-perishable food supply. All the appliances are clean and working properly. The common areas such as family room and dining room are clean and have the required furniture. The front and back yard are maintained well and the back yard has a shaded area and sitting area for client to utilize. LPA inspected the smoke detectors and carbon monoxide detectors and they are working probably. The sharp knives and utensils are stored in the kitchen cabinet under the sink and its locked and inaccessible to the clients. The chemical and cleaning supplies are stored in the locked cabinet in the garage.

LPA reviewed the clients' emergency contact information and they are all updated. LPA also reviewed 2 staff files and they are all background cleared and their health screening are also updated in their personnel files.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, facility is disinfected few times a day. The bathroom have sufficient soap, paper towels, and signs, and PPE supplies are sufficient for more than 30 days.

No deficiencies were observed during the visit and Exit interview conducted and a copy of the report was provided to the administrator Francine Campana
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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