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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603104
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:02:50 PM

Document Has Been Signed on 04/06/2022 04:02 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:TOMINES ADULT RESIDENTIAL FACILITY IFACILITY NUMBER:
198603104
ADMINISTRATOR:TOMINES, JONATHANFACILITY TYPE:
735
ADDRESS:6234 N BURTON AVETELEPHONE:
(626) 848-8836
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 3DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Alejandro Diel, StaffTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP Yolanda Cueto and explained the purpose of the visit. Staff Alejandro Diel arrived shortly after to assist with the visit. There are three (3) clients ages 18-59. The facility is a single-story home located in middle section of a multi-unit property. It is licensed for four (4) ambulatory clients. The home consists of three (3) bedrooms, 2 bathrooms, dining/kitchen, living room, backyard storage room, and attached garage with laundry area. The last emergency disaster drill was conducted on 4/1/2022. Administrator certificate expires 7/25/2022.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. LPA was screened upon entry. Visitor screening area/protocols are in place.
  • Facility has an approved COVID-19 mitigation plan. COVID-19 infection control signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing; with the exception of 1 bathroom.
  • Room #3 has been designated as a COVID-19 isolation room if needed
  • Three (3) centrally stored resident medication records were reviewed.
  • Residents in care do not wear masks because they lack hazard awareness and impulse control.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • A posted Emergency Disaster Plan was observed. Please update and send a copy to CCL.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Bedroom #3 is vacant. A luggage and staff personal belongings were observed. Administrator Jonathan Tomines stated it is not being used as a staff room, and all staff are awake during night shift. Jasmin Tomines stated the luggage belongs to a resident that was recently hospitalized.
*No deficiencies were cited.
Exit interview was conducted with staff Alejandro Diel. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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