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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603298
Report Date: 08/19/2022
Date Signed: 08/19/2022 12:48:06 PM

Document Has Been Signed on 08/19/2022 12:48 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:OTTERBEIN HOMEFACILITY NUMBER:
198603298
ADMINISTRATOR:CORONADO, TOMASAFACILITY TYPE:
735
ADDRESS:2017 OTTERBEIN AVETELEPHONE:
(626) 581-9192
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 4DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tomasa Coronado (Administrator)TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Tomasa Coronado (Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 18 through 59. Approved for (4) Ambulatory, of which (2) may be Non-Ambulatory.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen/dining room, attached garage/office/laundry room, 4 client bedrooms and 2 bathrooms. All medications for Clients are kept locked in the kitchen cabinet and inaccessible to other Clients. The bathrooms are clean and operational. Clients bedrooms were checked and furnishings to accommodate each Client comfortably was available. The hot water temperature was tested in the bathroom and measured within Title 22 Regulation guidelines. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked in the kitchen cabinet. All outdoor and indoor passageways are free of obstruction. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are secured and inaccessible to Clients. LPA reviewed staff records which contained criminal record clearance, current first aid and CPR. The Administrator's certificate is current. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and was fully charged. The first-aid kit is fully stocked w/First-aid Manual. A shaded area with chairs is provided in the back yard.

No deficiencies were observed during today's visit.

An exit interview was conducted with Tomasa Coronado and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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