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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603301
Report Date: 08/16/2021
Date Signed: 08/16/2021 02:17:53 PM

Document Has Been Signed on 08/16/2021 02:17 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:LAGUARDIA HOMEFACILITY NUMBER:
198603301
ADMINISTRATOR:CORONADO, TOMASAFACILITY TYPE:
735
ADDRESS:18615 LAGUARDIA STTELEPHONE:
(626) 581-1384
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 4DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Tomasa Coronado (Administrator)TIME COMPLETED:
02:30 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 Administrator Tomasa Coronado who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled Clients, ages range 18 through 59 years. 2 Ambulatory and 2 Non-Ambulatory.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, dining area, kitchen, attached garage/laundry, enclosed patio, 3 client bedrooms and 2 bathrooms. All medications for residents are kept locked and inaccessible to other residents and medications are labeled and maintained in compliance .The bathrooms are clean and operational. Clients bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested in bathroom #1 and measured within Title 22 Regulation guidelines. 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 in a secured cabinet and inaccessible to clients. All staff have a criminal record clearance. Smoke detectors and carbon monoxide detector are operable and in compliance. Land line located in the kitchen available for Client use. The fire extinguisher was observed in the kitchen area and is fully charged. The first-aid kit is fully stocked with first-aid Manual. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. There are no security bars, pools or bodies of water or fire arms on the premises.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to the Tomasa Coronado.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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