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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603343
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:51:28 PM

Document Has Been Signed on 04/23/2024 03:51 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/
DIRECTOR:		VITANGCOL, FLORENTINOFACILITY TYPE:
735
ADDRESS:211 S. SHIPMAN AVE.TELEPHONE:
(909) 904-0895
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 6DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Administrator Florentino VitangcolTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with Administrator Florentino Vitangcol and the purpose of the visit was discussed.

Physical Plant and Environmental Safety: The facility is licensed to serve six (6) clients of ages between 18-59 of which one (2) may be non-ambulatory. There are currently six (6) clients who are placed by the San Gabriel Pomona Regional Center of which (1) is non-ambulatory. Facility is located in a residential area and consist of a Living room, dining area, kitchen, (4) client bedrooms, 2 bathrooms and a laundry room. The facility was inspected during the physical plant tour. No passageways or paths were obstructed. Front and backyard also observed.

Health Related Services: Medication is centrally stored and locked making them inaccessible to clients in care. LPA reviewed six (6) Client Medications. No errors observed.

Due to time constraints, LPA was only able to complete two (2) of twelve (12) domains during the visit. No deficiencies are being cited on todays visit. LPA to return at a later date to complete annual inspection.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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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