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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603368
Report Date: 08/19/2024
Date Signed: 08/19/2024 01:03:56 PM

Document Has Been Signed on 08/19/2024 01:03 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/
DIRECTOR:		TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:540 N. FOXDALE AVETELEPHONE:
(626) 337-7782
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 4DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Staff - Corazon BondocTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nune Margaryan and Mayra Cota conducted an unannounced annual visit. LPAs met with staff Corazon 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 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. Three (3) 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 / den, kitchen, 4 bedrooms, 2 bathrooms and the garage. Laundry area was observed in the garage. LPAs observed laundry detergent are stored in the garage and garage door was not locked. The front and backyard are well maintained and there are no pools or large bodies of water. LPAs observed a wood canopy in the backyard for the clients but without tarp cover. Passageways and exits are free of obstruction. There is a activity supplies caddy in the corner of den. LPAs observed the metal hammer in the supplies caddy. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. 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.

Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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Document Has Been Signed on 08/19/2024 01:03 PM - It Cannot Be Edited


Created By: Nune Margaryan On 08/19/2024 at 11:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOXDALE HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed Laundry detergent unlocked in the laundry area located in the garage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Laundry detergent were locked immediately. Cleared at the time of visit.
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed the hummer with the activity supplies in the den was not locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Hummer was locked immediately. Cleared at the time of visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/19/2024 01:03 PM - It Cannot Be Edited


Created By: Nune Margaryan On 08/19/2024 at 11:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOXDALE HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. There is a wood canopy in the backyard but without tarp cover, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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Administrator to send receipt of the tarp cover and photo that it has been installed to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


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: 08/19/2024
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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. 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.

Deficiencies were noted on LIC 809D.



Exit interview was conducted with Administrator Olivia Tomines and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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