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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603343
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:55:33 PM

Document Has Been Signed on 04/07/2022 03:55 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: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:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:VITANGCOL, FLORENTINOTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with administrator VITANGCOL, FLORENTINO and explained the reason for the visit and also assisted LPA with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients files. Facility has submitted a mitigation plan and was approved on 04/18/2021. The facility cares for developmentally disable adults and is vendorized by San Gabriel/Pomona Regional Center as a Level 4C home.

The facility is a single story house and located in a residential neighborhood area. The facility included a living room, dining area/staff office, kitchen, four clients rooms, two clients bathrooms. The laundry room is located at the patio. All 4 clients bedrooms were toured. Bedroom#1 and #4 have two beds, two dresser, night stand, required linen and sufficient lighting and closet space. Bedroom #2 and #3 have one bed, one dresser, one chair, one night stand , required bed linen, sufficient lighting and closet space. All 2 bathrooms were toured and they are clean and sanitary. The hot water was measured at two bathrooms are between 107.9 and 110.6 degrees F which is within Title 22 regulation. The food supply in the refrigerator and kitchen cabinet are sufficient for two days perishable and seven days non-perishable. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The exit and passage ways are free of obstruction. The front porch and back yard are maintained well and the front and back yard both have a shaded area with tables and chairs for clients and visitors to utilize. The cleaning supplies are stored and locked in the cabinet outside the patio The knives and sharp utensils are locked and stored under the sink and its inaccessible to clients. The medication are centrally stored and locked in the medication cabinet near the dining area. LPA also inspected clients medication and they are accurate and updated. And all clients' emergency contact information are current and up-to dated. LPA also inspected the smoke detectors and carbon monoxide detectors and they are interconnected and working properly.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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 2
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: 04/07/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in the common area and facility is disinfected every shift and all day frequently. The bathrooms and the cabinet outside the patio have sufficient soap, paper towels, and signs. PPE supplies are sufficient for more than 30 days.

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

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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