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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603325
Report Date: 04/04/2022
Date Signed: 04/04/2022 10:39:42 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/04/2022 10:39 AM - 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:EMJ HOME CAREFACILITY NUMBER:
198603325
ADMINISTRATOR:TORRES, MICHAELFACILITY TYPE:
735
ADDRESS:1486 LASSITER DRIVETELEPHONE:
(909) 957-5620
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 5CENSUS: 5DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Alicia Canlas, House ManagerTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with house manager Alicia Canlas and explained the reason for the visit. LPA and House manager Alicia Canlas toured the facility together.

Facility is licensed to served 5 clients between the age of 18 and 59 years old, which 5 shall be ambulatory and 1 non-ambulatory. The facility is a single story building in a residential area, with a commercial kitchen, 5 bedrooms 2 bathroom, 1 private bathroom, dining room, living room, garage and backyard with shaded sitting area. Carbon monoxide detectors and smoke detectors were tested and in working condition. Fire extinguishers were fully charged and located in the kitchen and hallway.

LPAs toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications. Administrator certificate was observed current with #6043086735. Latest disaster drill conducted on 4/2/22.

LPA toured the kitchen and observed sufficient food supplies of 7 days of non- perishables and 2 days perishables. Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The backyard are well maintained. The resident bathrooms are clean, and has the required signs, soap and . The hot water temperature measured between 105 - 120 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to house manager Alicia Canlas.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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