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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603343
Report Date: 11/17/2021
Date Signed: 11/29/2021 11:41:26 AM

Document Has Been Signed on 11/29/2021 11:41 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:JFVITACARE1 CORP.FACILITY NUMBER:
198603343
ADMINISTRATOR:VITANGCOL, FLORENTINOFACILITY TYPE:
735
ADDRESS:211 S. SHIPMAN AVE.TELEPHONE:
(909) 904-0895
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 6DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Christina Rojas TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with DSP Christina Rojas and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedure and observed food supply. Facility has submitted a mitigation plan and was approved on 04/24/2021.

The facility is located at a residential neighborhood. The facility consists of living room, dining area, kitchen, four clients bedrooms, two bathrooms. The laundry room is located at the side of the back yard. All four clients bedrooms were toured. Bedroom#1 has two beds, two night stands, required furniture and linen and sufficient lighting and closet space. Bedroom#2 and #3 have one single bed, night stand, dresser, required furniture and linen, sufficient lighting and closet space. Bedroom#4 has two beds, two night stands, required furniture and linen, sufficient lighting and closet space. All two bathrooms were toured and they are clean and maintained in good condition. The hot water temperature was tested between 107.6 and 108 degrees F. which is within the Title 22 regulation. For the food supply, the refrigerator and the cabinet in the kitchen has sufficient for two days perishable and seven days non perishable food. All the appliances in the kitchen are working properly. The sharp utensils and knives are locked under the sink. The common area and dining area are clean and have the required furniture. LPA tested the smoke detectors and carbon monoxide detectors and they are all interconnected and operated well. The front yard and back yard are maintained well. The backyard has shaded area and sitting area. The passageway and exits are free of obstruction. The medication are centrally stored and locked in a cabinet next to the dining table. All the cleaning products are locked in a cabinet next to the laundry room.

(See LIC809C for continuation)


SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JFVITACARE1 CORP.
FACILITY NUMBER: 198603343
VISIT DATE: 11/17/2021
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing, facility is being disinfected every shift or time to time, The facility also have sufficient soap, paper towels, and signs. The PPE supplies are stored for more than 30 days.

No deficiencies were found during this visit. Exit interview was conducted with DSP Christina Rojas and a copy of this report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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