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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603368
Report Date: 09/11/2023
Date Signed: 09/11/2023 12:12:14 PM

Document Has Been Signed on 09/11/2023 12:12 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:FOXDALE HOME ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603368
ADMINISTRATOR:TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:540 N. FOXDALE AVETELEPHONE:
(626) 337-7782
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 4DATE:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jose Bondoc and Olivia TominesTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Nune Margaryan and Sanjay Vaid conducted an unannounced annual visit using the CARE tool. LPAs met with staff Jose Bondoc who assisted with the visit. Administrator Olivia Tomines arrived shortly after. LPAs explained the reason for the visit. LPAs used the infection control tool to evaluate the facility. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. Facility submitted infection control plan to CDSS. The facility is licensed to serve developmentally disable clients between the ages 18 to 59. There are currently 4 clients residing at the home and receive services from San Gabriel / Pomona regional Center. Two (2) clients were at the Day program at the time of visit. The facility is located in a residential area. LPAs toured the home and inspected living room, dining room, kitchen, 4 bedrooms, 2 bathrooms and the garage. Laundry area was observed in the garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. LPAs observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the garage. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. All staff were observed to be wearing mask upon entrance and during visit. Client bedrooms were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathrooms were toured. Bathrooms are clean and have the required hygiene items. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients.

The fire extinguishers ( one in the kitchen and one in the garage) observed to be fully charged. Smoke/carbon monoxide detector observed to be fully operational. LPAs observed the centrally stored medications area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FOXDALE HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603368
VISIT DATE: 09/11/2023
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LPAs reviewed client's files and observed that all files are updated. LPAs confirmed staff working have fingerprint clearances. LPAs reviewed clients medications. Medications are documented properly and given as prescribed.
No deficiency was observed during today's visit. Exit interview was conducted with Administrator and a copy of report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
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