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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603371
Report Date: 10/12/2021
Date Signed: 10/12/2021 02:32:03 PM

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:CANDLELIGHT HOME GARDENGLENFACILITY NUMBER:
198603371
ADMINISTRATOR:CALINGASAN, GILFACILITY TYPE:
735
ADDRESS:419 SOUTH GARDENGLEN STREETTELEPHONE:
(626) 715-5653
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:4CENSUS: 2DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jane Cua; AdministratorTIME COMPLETED:
02:46 PM
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with DSP Anthony Mallari and explained the reason for the visit. Administrator Jane Cua arrived shortly thereafter. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Administrator toured the home and inspected (4) client bedrooms, (2) bathrooms, kitchen, dining room, living room, office room, activity room and attached 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 residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and bathroom #2 and measured between 116.5F - 116.7F which is within the required 105 - 120 degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector in the hallway of the home that was tested and operable. There is a fire extinguisher located in the living room area which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked under the kitchen sink and are inaccessible to clients. Cleaning supplies and toxins are locked under the kitchen sink and are inaccessible to clients. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (2) out of the (2) client medications were reviewed. Medications are centrally stored in a closet located by the dining room. Medications are documented properly and given as prescribed.
  • Staff and Client files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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