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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603361
Report Date: 06/08/2023
Date Signed: 06/09/2023 08:10:11 AM

Document Has Been Signed on 06/09/2023 08:10 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HASU COMPASSIONATE CARE HOMEFACILITY NUMBER:
198603361
ADMINISTRATOR:JANET OBONGFACILITY TYPE:
735
ADDRESS:20312 SHADOW MOUNTAIN RD.TELEPHONE:
(909) 631-8521
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 4CENSUS: 4DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Janet Obong, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection. LPA arrived unannounced and met with Administrator, Janet Obong. The purpose for the visit was explained. The facility is licensed for 4 non-ambulatory adults, ages 18 - 59, of which 1 may be bedridden. Bedrooms #1 or #3 are approved for bedridden.

LPA toured the facility and conducted the following domains:
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting daily and more often for high touched surfaces. Facility has sufficient PPE supplies and still screening for COVID-19 symptoms.
Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 3 client bedrooms, staff room, administrator's office, 2 bathrooms, living room, dining room, kitchen, and an attached garage. Each client bedroom has the required furniture and bedding. Extra hygiene supplies were observed. The smoke detectors are interconnected and alerts the local fire department when alarmed. There is an operable carbon monoxide detector located in the bedroom hallway. Knives, cleaning solutions, and disinfectants are locked and not accessible to clients. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F.
Operational Requirements: The facility is licensed for (4) adults ages 18 - 59. There are currently 4 clients residing at the home and were placed by the San Gabriel/Pomona Regional Center.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. Freezers are maintained at a temperature of 0 degree F and the refrigerators at a maximum of 45 degrees F. Both are kept clean and food are properly stored.

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 the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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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