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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603325
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:06:49 PM

Document Has Been Signed on 04/11/2023 04:06 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: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:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sandra Alcala, StaffTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Staff, Sandra Alcala. The purpose of the visit was explained. The house manager, Alicia Federspiel, arrived shortly after to assist with the visit. The facility is licensed for (5) adults, ages 18 - 59, of which 1 may be non-ambulatory.

LPA toured the facility and conducted the following domains:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least twice a day and more often for high touched surfaces. Facility has sufficient PPE supplies. The facility had previously submitted the Infection Control Plan.
Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 5 client bedrooms, 3 bathrooms, living room, kitchen, and attached garage. Each client bedroom has the appropriate furniture, storage space, and lighting. Extra hygiene supplies were observed. Facility has an operable smoke detector in each room and a carbon monoxide detector. Knives, cleaning solutions, and disinfectants are locked. There are no firearms or weapons stored at the facility. The hot water temperature was measured between the required range of 105-120 degrees F.
Operational Requirements: The facility is operating within the fire clearance approval. Staff are providing care and supervision to meet the clients' needs and assisting in activities of daily living.
Food Service: There are sufficient food supplies of 2 day perishable and a week of non-perishable items observed. Foods are properly stored in the refrigerator to avoid contamination.

LPA will return to complete the remainder of the domains on a later date. An exit interview was conducted and a copy of this report was given to the house manager.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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