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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603104
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:46:53 PM

Document Has Been Signed on 03/14/2024 04:46 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: 4DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Jasmin Tomines, Assistant AdministratorTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to DSP Yolanda Cueto. Assistant Administrator arrived shortly after. The facility is licensed for 4 ambulatory level 4I developmentally disabled residents 18-59 years old vendored by Eastern Los Angeles Regional Center.

Infection Control:

  • COVID-19 screening is still in place. Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an updated Infection Control Plan.
  • Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed for four (4) ambulatory clients. It consists of 3 client bedrooms, living room/dining room, kitchen, 2 bathrooms, backyard patio area, and attached garage. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operational. There are two (2) fire extinguishers in the facility. Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
  • Operational Requirements: Fire clearance is approved for four (4) ambulatory only residents. Care and supervision to meet the clients needs was observed. Special equipment and supplies are used by residents. The Surety Bond is current with expiration date of 10/4/2026. The facility has current liability insurance.
  • Staffing: A total of eight (8) staff members provide care and supervision to the clients.
  • Personnel Records/Staff Training: Administrator certificate expires 7/25/2025. Four (4) staff files were reviewed. Personnel record, Criminal Record Clearance, health screening/TB clearance, training, zero-tolerance policy, and 1st Aid/CPR was on file.
  • Client Rights/Information: Physician orders, and personal rights were reviewed in client files.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TOMINES ADULT RESIDENTIAL FACILITY I
FACILITY NUMBER: 198603104
VISIT DATE: 03/14/2024
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  • Client Records/Incident Reports: Four (4) resident files containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, Personal & Incidental (P & I) monies/records, and Medication Administration Records were reviewed.
  • Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. One resident has physician orders for modified (pureed) diet.
  • Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Centrally stored resident medication records were reviewed. All medications were observed in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.
  • Incident Medical and Dental: All residents have Needs and Services Plans, Physician Reports, and COVID-19 vaccination cards on file.
  • Disaster Preparedness, and Emergency Intervention: LIC 610E Emergency Disaster Plan that contains emergency evacuation information was reviewed and is posted. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed.The last emergency drill was conducted on 3/1/2024.
  • Emergency Intervention: No manual restraints or seclusion are used with clients in care.


No deficiencies were cited.


Exit interview was conducted with Assistant Administrator Jasmin Tomines. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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