198603371-11-14-2023-28-AS-KRAZ-CXL33W-20231114165412

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603371
Report Date: 11/14/2023
Date Signed: 11/14/2023 04:54:25 PM

Document Has Been Signed on 11/14/2023 04:54 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:	CANDLELIGHT HOME GARDENGLEN		FACILITY NUMBER:	198603371
ADMINISTRATOR:	CALINGASAN, GIL		FACILITY TYPE:	735
ADDRESS:	419 SOUTH GARDENGLEN STREET		TELEPHONE:	(626) 715-5653
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 4		CENSUS: 3	DATE:	11/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Daniel Baluyot-House Manager		TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 11/14/2023. LPA Ramirez was met by House Manager Daniel Baluyot and explained the purpose of the visit. The facility is licensed serve four (4) developmentally disabled clients 18-59 years old. The facility is a 4I level home. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020). All clients in the home receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: Tour began at 2:25 pm. The facility is a single story dwelling located in a residential area with four (4) client bedrooms, one (1) staff office, one (1) activities room, two (2) bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard.

Front Yard: LPA Ramirez observed front yard to be free of hazards.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to three (3) out of three (3) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to three (3) out of three (3) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby. Kitchen sink temperature was measured at 113.3 degrees F.

Dining Room/Living room: Dining room was observed to contain one table with five (5) chairs. Living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and handwashing etiquette in this area. LPA Ramirez observed nearby thermostat to read 74 degrees F. LPA Ramirez observed Client#1 (C1) wearing a black helmet, coloring with crayons in living room area. LPA observed C1 take off helmet without assistance.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CANDLELIGHT HOME GARDENGLEN	FACILITY NUMBER: 198603371
	VISIT DATE: 11/14/2023

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Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. Client bedroom#2 is currently unoccupied.

Bathroom 1-2: LPA Ramirez observed grab bars in all showers and non slip mats in all bathrooms showers. LPA Ramirez observed signage promoting proper handwashing etiquette near sink.

Centrally Stored Medications: LPA Ramirez observed medications to be inaccessible to three (3) out of three (3) clients in care. Medications cabinet is located near staff office.

Backyard: No large bodies of water were observed and area was free of hazards.

Emergency Drills: Proof of last documented emergency drills were conducted on 09/03/23 and 08/29/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed four (4) staff files. LPA Ramirez observed current Administrators Certificate with an expiration date of 01/13/24 for Harold Fajardo.

Client Files: Three (3) client files were reviewed. LPA Ramirez did not observe an exception granted for protective helmet for C1 during client file review. LPA will issue technical violation.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

Exit interview was conducted. No deficiencies were cited, one (1) technical violation was observed and noted. A copy of this report, LIC 9102, and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

LIC809 (FAS) - (06/04)

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