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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603303
Report Date: 07/12/2024
Date Signed: 07/12/2024 12:37:16 PM

Document Has Been Signed on 07/12/2024 12:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PASO REAL HOMEFACILITY NUMBER:
198603303
ADMINISTRATOR/
DIRECTOR:		GLICKMAN, PAMELAFACILITY TYPE:
735
ADDRESS:1918 PASO REAL AVETELEPHONE:
(626) 810-1945
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 4DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Lilia Raymundo, House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 7/12/24. LPA arrived unannounced and met with the house manager, Lilia Raymundo. The purpose of the visit was explained. The facility is licensed for (4) adults, ages 18 - 59, of which 4 may be non-ambulatory.

LPA used the Compliance and Regulatory Enforcement (CARE) tool to inspect the facility. LPA toured the facility, reviewed files, and conducted interviews. The facility does not have any pools or bodies of water on the premises. The facility consist of 4 rooms in which 2 are used as client bedrooms, 1 staff office, and 1 storage room. There are 2 bathrooms, double living room, dining area, kitchen, and a garage. The client bedrooms have appropriate furniture and storage space. There are extra linens and hygiene supplies. Facility has smoke detectors in each room and carbon monoxide detectors. Knives and cleaning products are locked. Staff are continuing to follow their infection control plan. Staff are providing care and supervision to meet the clients' needs. LPA observed sufficient food supplies of 2 day perishable and a week of non-perishable items. Foods are properly stored in the refrigerator to avoid contamination. There is sufficient staffing on each shift. Facility has an awake staff in the overnight shift to supervise clients. Staff are all fingerprint cleared and associated to the facility. LPA reviewed records for 4 staff and 4 clients. They all have the required documents in their files. Facility staff have current CPR & First Aid training. They do not use any manual restraints on clients. There are no clients with a restricted health condition. Medications are centrally stored and locked. LPA reviewed medications and they are being administered as prescribed. The facility has the updated emergency and disaster plan and conducting monthly drills.

There are no deficiencies issued today. An exit interview was held and a copy of this report was given to the staff.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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