<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603313
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:23:00 PM


Document Has Been Signed on 05/08/2023 03:23 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:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jossen Maglalang (Direct Support Professional)TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. 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.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, family room, attached garage/laundry area, dining area, kitchen, 3 resident bedrooms, 1 staff bedroom and 2 bathrooms.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools containing the following domains: Infection Control, Physical Plant & Environment Safety, Staffing, Personnel Reports-Training, Food Services.

During today's visit, LPA observed the following: Facility has maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. No pools and bodies of water on the premises. The licensee provides hygiene items of general use such as soap and toilet paper. Hot water temperature measured at 106.3 degrees F in bathroom #1. There is a presence of grab bars for each toilet, bathtub and shower used by residents. Lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility was observed. The total daily diet is of the quality and in the quantity necessary to meet the resident’s needs. Minimum of one week supply of nonperishable foods and 2 days of perishable foods observed. Pesticides and other toxics are not stored in food storerooms. All individuals subject to a criminal record review has obtained a clearance or criminal record exemption. Licensee has completed an individual written admission agreement with each resident. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation.

Due to time constraints, LPA will return to the facility at a later date to complete the Annual Inspection. There are no deficiencies observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Jossen Maglalang.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1