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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603125
Report Date: 04/15/2022
Date Signed: 04/15/2022 01:39:01 PM

Document Has Been Signed on 04/15/2022 01:39 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:INDIVIDUALS FIRST CORPFACILITY NUMBER:
198603125
ADMINISTRATOR:VITANGCOL, JEFFREYFACILITY TYPE:
735
ADDRESS:991 W 3RD STTELEPHONE:
(909) 641-2058
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 3DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jeffrey VitangcolTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Facility Administrator and explained the purpose of today's visit.

This home consists of (4) bedrooms, (2) bathrooms, living room, kitchen, dinning area, laundry room and attached garage. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility. Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed inside a cabinet (dinning area). Additional PPE supplies are stored inside garage.
  • Hygiene and incontinence supplies observed. Items stored inside the garage.
  • Restrooms have hand soap, hand sanitizer and paper towels. Hand sanitizer observed throughout the facility.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Emergency food supply is stored inside the garage.
  • Per Administrator, (3) clients and staff are fully vaccinated including the Booster.
  • Medication reviewed for (3) Clients (Client #1 through Client #3).
  • Staff responsible for direct care and supervision will wear masks.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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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