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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603350
Report Date: 05/09/2023
Date Signed: 05/09/2023 05:28:26 PM

Document Has Been Signed on 05/09/2023 05:28 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: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:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Christine Takata, CaregiverTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Staff, Christine Takata. The purpose of the visit was explained. Administrator, Arlisha York, arrived at 3:20pm to assist with the visit. The facility is licensed for (4) ambulatory clients, ages 18 - 59.

LPA toured the facility and conducted the following domains:

Infection Control: The facility staff are using appropriate hand hygiene and wear gloves when needed to assist clients. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces. Facility has sufficient PPE supplies.
Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 3 client bedrooms, 2 bathrooms, living room, dining area and open kitchen, and an attached garage. Each client bedroom has the required furniture and bedding. Extra hygiene supplies and linens are observed. The smoke detectors are interconnected and the carbon monoxide detector are operable. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to clients. There are no firearms or weapons stored at the facility.
Operational Requirements: The facility is operating within the approved fire clearance. Staff are providing the care and supervision as necessary to meet the clients' needs.
Food Service: There are sufficient food supplies of 2 day perishable and a week of non-perishable. The kitchen is clean and free of pests.
LPA also checked the medication for 3 clients and they are being administered as prescribed by the physician.
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 Administrator York.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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