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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603350
Report Date: 05/18/2022
Date Signed: 05/18/2022 11:17:22 AM

Document Has Been Signed on 05/18/2022 11:17 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:DAVID ADULT RESIDENTIAL HOMEFACILITY NUMBER:
198603350
ADMINISTRATOR:YORK, ARLISHAFACILITY TYPE:
735
ADDRESS:562 SLOPE DRIVETELEPHONE:
(909) 612-7436
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 4CENSUS: 3DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Andre Simon, DSPTIME COMPLETED:
11:30 AM
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Licensing Program Analyst's (LPA's) Vasallo conducted an annual required visit. LPA met with staff member, Andre Simon and explained the reason for the visit. Administrator, Arlisha York was notified via phone of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records and observed the food supply, The facility cares for adults with developmental disabilities and is vendorized by San Gabriel/Pomona Regional Center as a Level 4I facility.

All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. Both client bathrooms were toured and the hot water was 118.2 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. There is a screening station at the entrance of the home which has PPEs and a thermometer to screen visitors. Staff document client temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs. There are cameras inside and outside the home only in common areas.

Client files were reviewed to confirm emergency contacts are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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