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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603201
Report Date: 03/03/2022
Date Signed: 03/03/2022 11:08:58 AM

Document Has Been Signed on 03/03/2022 11:08 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:HEART TO HOME RESIDENTIAL FACILTYFACILITY NUMBER:
198603201
ADMINISTRATOR:MINES, JASMINEFACILITY TYPE:
735
ADDRESS:795 E ELIZABETH STTELEPHONE:
(626) 233-0725
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 3DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Kurtgiraff Rumbaua - Direct Support Staff
Kenia Williams - Direct Support Staff
TIME COMPLETED:
11:20 AM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection domain, food, and medication review. LPA Flores met with Kurtgiraff Rumbaua Direct Support Staff (DPS) and explained the reason for the visit.

Facility is licensed to serve 6 ambulatory adults between the age of 18-59 years old. The facility is a single story home located in a residential area with 3 client bedrooms, 2 bathrooms, a kitchen, a dining room, a living room, a staff bedroom, laundry room, office, a front porch, and a backyard with shaded sitting area. No large bodies of water were observed. Smoke detectors were tested and in working condition.

LPA Flores conducted a tour of the facility with Kurtgiraff Rumbaua - DPS and observed the following:
Medication cabinets were observed in living room and locked. Cleaning supplies and sharps were observed in the kitchen and kept locked. There is sufficient food for at least 2 days of perishables and 7 days of non-perishables. All bedrooms have sufficient lighting, the required furniture and bedding supplies. Water temperature was tested in bathroom #1 at 109.6 degrees F and bathroom #2 at 110.8 degrees F. which is within the required 105-120 degrees F. LPA Flores reviewed medication and files for client #1, and #2 and staff files for staff #1, and #2. Administrator certificate was observed for Hazel Gatan #6031261730 expiration date: 8/27/22.
All COVID recommendations are being followed by the facility.

No Deficiencies were given during this visit.

Exit interview was conducted with Kurtgiraff Rumbaua direct support staff and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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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