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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603350
Report Date: 05/11/2023
Date Signed: 05/11/2023 07:27:02 PM

Document Has Been Signed on 05/11/2023 07:27 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:
05/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Glauce Vance, CaregiverTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue with the annual inspection. LPA arrived unannounced and met with Staff Glauce Vance. On 5/9/23, LPA began the annual inspection using the CARE tools.
During the visit today, LPA completed the remainder of the domains from the CARE tools.
Staffing: The facility has sufficient staffing to cover all shifts and one staff awake at night to supervise clients.
Personnel Records-Training: LPA reviewed the administrator and 2 other staff files. The files have the required documents such as health screening with TB results and current CPR/First Aid certificates. They are fingerprint cleared and associated to the facility. Staff have sufficient training to provide care and supervision to clients.
Client Rights - Information: There are no clients who utilize any postural supports. The clients have internet access device for client use.
Client Rights - Incident Reports: LPA reviewed 3 client files. They were placed by the San Gabriel/Pomona Regional Center. The files contained the admission agreement, medical assessment with TB results, annual IPP reports, and behavior assessment conducted by the facility.
Health-Related Services: The medication are given as prescribed by the physician. They come in bubble packs and the labels have not been altered.
Incidental Medical Services: The clients are seen by a licensed medical professional monthly. There are no clients who are insulin-dependent diabetics nor do they have any other restricted health conditions.
Disaster Preparedness: The facility has an updated Emergency Disaster Plan which includes emergency contact numbers, at least 2 appropriate shelter locations, and utility shutoff valves.

No deficiencies were observed today. LPA provided a technical assistance for quarterly disaster drills. An exit interview was held. A copy of this report and LIC
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
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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