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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603372
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:43:28 PM

Document Has Been Signed on 07/27/2023 03:43 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:FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLEDFACILITY NUMBER:
198603372
ADMINISTRATOR:DONELSON, VALERIEFACILITY TYPE:
735
ADDRESS:1363 DEVERON PLACETELEPHONE:
(626) 756-7820
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Arrion Quinn and Valerie DonelsonTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Arrion Quinn and discussed the purpose of today’s visit. Valerie Donelson (Administrator) arrived at approximately 10:10 A.M..

This home consists of 3 bedrooms, 2 baths, kitchen, dining area, living room and attached garage. There are (4) clients residing at this home. All clients receive case management services provided by San Gabriel Pomona Regional Center. Fire Clearance is for (4) ambulatory clients.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: Last Disaster Drill was conducted on 05/26/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms were tested and operable. Fire extinguisher is located near the dining table and was last serviced on 09/15/22. Carbon monoxide detector is located in the kitchen (tested and operable). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured at: 110.0*.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED
FACILITY NUMBER: 198603372
VISIT DATE: 07/27/2023
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Staffing: There is sufficient staffing at the facility. Administrator Certificate for Valerie Donelson expires 12/02/23. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) through Staff #3 (S-3). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff have on-going training.

Client Rights-Information: Client rights are posted and included in Client files. Per Administrator, there are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, Individual Program Plan (IPP), House Rules, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Additional food supplies are stored in the garage. Per Administrator, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and bubbled packed. LPA reviewed medication for C-1 through C-4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per Administrator, there are (0) clients with restricted health condition plan.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place.

Exit interview, appeals rights and a copy of this report was provided to Valerie Donelson.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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