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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 10/20/2021
Date Signed: 10/20/2021 03:44:18 PM

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:WHITTIER GLEN ASSISTED LIVINGFACILITY NUMBER:
198603162
ADMINISTRATOR:ATEAIAN, KIMIAFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:93CENSUS: 54DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Sophia Chan TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an un-announced Annual visit with focus on Infection Control. LPA met with Administrator Sophia Chan. The purpose of the visit was discussed.

LPA Villalobos discussed infection control practices with staff, toured the facility inside and out between 10:30am-11:15am, reviewed food supply, reviewed five (5) resident files along with their medications between 11:30am-12:30pm, and reviewed five (5) staff files between 1pm-1:45pm. The facility physical plant consists of a two story building structure that contains the following: First floor consists of resident rooms with individual bathrooms, 1 living room, Dining Rooms, courtyard, 3 offices, medication room, kitchen, and laundry area. Physical plant inside and outside is clean, sanitary and in good repair. The facility second floor consists of the following: resident bedrooms with individual bathrooms, laundry room, outdoor porch seating area, and Activity room. The following was observed: Bedrooms #106 #110 #128 and 202 were observed. All rooms have required furniture and supplies. Facility had an area with locked cabinet for medications. Facility is clean and in good repair. Water temperature met Title 22 Regulations measuring between 105-120 F. .Cupboards, freezer, stove, microwave, refrigerator and counters are clean. Bathrooms for the above mentioned rooms were observed and meet title 22 regulations. There was a 7 day supply of non-perishables available and a 2 day supply of perishables available. Client records inaccessible to unauthorized persons and will be located in a locked cabinet. Emergency disaster plan, personal rights and complaint procedures are posted. First Aid Kit and manual is complete and readily available. Smoke detectors and carbon monoxide detector operate properly and fire extinguishers are properly charged. Working washers and dryers. Working telephone. There are no bodies of water located on the premises. Adequate seating in common areas for licensed capacity. Furniture in all facility rooms appropriate, clean and in good repair. There is an outdoor activity space/ patio with a shaded area and furnished for outdoor use.

Visit was completed using the Infection control inspection tool. No deficiencies were cited on todays visit. Exit interview was conducted and a copy of report was provided to Sophia Chan.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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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