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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603104
Report Date: 05/12/2023
Date Signed: 05/15/2023 08:34:45 AM


Document Has Been Signed on 05/15/2023 08:34 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
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:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Jasmin Tomines, Assistant AdministratorTIME COMPLETED:
05:10 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 met with DSP Eleonor Lopez and explained the purpose of the visit. Assistant Administrator Jasmin Tomines arrived shortly after. There are four (4) ambulatory developmentally disabled clients in the home. The facility is licensed as a level 4i Adult Residential Facility (ARF) vendored by Eastern Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. Each client room is designated as a COVID-19 isolation room if needed. An Infection Control Plan and COVID-19 Mitigation Plan was reviewed.


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.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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
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: 05/12/2023
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:
  • All clients have a Needs and Services Plan an on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. However, the most current LIC 610D required has not been completed. A technical advisory was issued.
  • An emergency drill was conducted on 5/3/2023. The facility shall conduct a drill at least quarterly for each shift.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.


No deficiencies cited.

Exit interview conducted with Assistant Administrator Jasmin Tomines. A copy of the report and technical advisory was issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 05/12/2023
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Operational Requirements:
  • The Program Design was reviewed.
  • Fire clearance was approved by LA County Fire Department for four (4) ambulatory clients.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Client (C2) has hospital bed with a half rail physician order.
  • Current Surety bond and Certificate of Liability Insurance were reviewed.

Staffing:
  • A total of seven (7) staff members provide care and supervision to the clients. *The detached storage building in the backyard is used as a "resting" area for staff. NOTE: Plan of Operation states all staff shall be awake 24 hours a day.

Personnel Records/Staff Training:
  • Administrator certificate expires 7/25/24.
  • Five (5) staff files were reviewed for criminal background clearance and training.
  • Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:
  • Physician orders for postural supports were reviewed in client files.

Client Records/Incident Reports:
  • Three (3) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records, Restricted Health Care Plans, and P & I money 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.
  • Client (C1) has physician orders for a modified diet.

See next page.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3