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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603313
Report Date: 05/11/2023
Date Signed: 05/11/2023 02:16:03 PM

Document Has Been Signed on 05/11/2023 02:16 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:TONOPAH HOME LIVINGFACILITY NUMBER:
198603313
ADMINISTRATOR:NGO, ANTHONYFACILITY TYPE:
740
ADDRESS:333 TONOPAH AVE.TELEPHONE:
(626) 363-4343
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 5DATE:
05/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Jossen Maglalang (Direct Support Professional)TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for a Case Management - Annual Continuation. Upon arriving at the facility, LPA met with Jossen Maglalang (Direct Support Professional) and explained the purpose of the visit. The facility is licensed to serve age range 60 and over. Approved for (4) ambulatory. Approved for (2) non-ambulatory.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Operational Requirements, Client Rights - Information, Client Records-Incident Report, Health Related Services, Incidental Medical Services, Disaster Preparedness, Emergency Intervention.

During today's visit, LPA observed the following: The facility has maintained a current, written definitive plan of operation. The facility maintain a fire clearance approved by the city. Client records contain the admission agreement, pre-admission appraisal and physical examination. Licensee posted the personal rights, nondiscrimination notice, and complaint information. Outdoor activity area are easily accessible to residents. Gardens or yards are sufficient in size, comfortable and appropriately equipped for outdoor use. The licensee provides assistance in meeting necessary medical and dental needs. The facility has an emergency and disaster plan. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible to persons other than employees responsible for the supervision of the centrally stored medication.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Jossen Maglalang.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
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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