198603371-9-9-2024-28-AS-NMAN-D8XQVC-20240909123007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603371
Report Date: 09/09/2024
Date Signed: 09/09/2024 12:30:17 PM

Document Has Been Signed on 09/09/2024 12:30 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:	CANDLELIGHT HOME GARDENGLEN		FACILITY NUMBER:	198603371
ADMINISTRATOR/ DIRECTOR:	JANE CUA		FACILITY TYPE:	735
ADDRESS:	419 SOUTH GARDENGLEN STREET		TELEPHONE:	(626) 715-5653
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 4		CENSUS: 4	DATE:	09/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Jane Cua		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit. LPA met with Administrator who assisted with the visit. LPA explained the reason for the visit. LPA 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. LPA toured the home and inspected living room, dining room, kitchen, 4 bedrooms, activity room / family area, office area, 2 bathrooms and the garage. Laundry area was observed in the garage. LPA observed laundry detergent are stored in the garage and locked in the cabinet. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded seating area for the clients located in the backyard. 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. LPA observed plenty linens, towels and hygiene supplies in the linen/supply closet in the dining room. Fire extinguisher observed in the facility fully charged. Fire drill was / Quarterly Disaster Drill was conducted on 09/01/24

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SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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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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: CANDLELIGHT HOME GARDENGLEN	FACILITY NUMBER: 198603371
	VISIT DATE: 09/09/2024

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Carbon monoxide/smoke detectors in the hallways and in the client rooms are operational. Centrally stored medications are stored in a locked cabinet next to the office area. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

No deficiency was observed during today's visit. Exit interview was conducted and a copy of report was provided to Administrator.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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