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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603375
Report Date: 10/13/2022
Date Signed: 10/31/2022 08:24:28 AM

Document Has Been Signed on 10/31/2022 08:24 AM - 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:CASA COLINA- TRANSITIONAL LIVING CENTERFACILITY NUMBER:
198603375
ADMINISTRATOR:WOLFSON, BRIANFACILITY TYPE:
735
ADDRESS:301 MULBERRY DR.TELEPHONE:
(909) 596-7733
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Stephanie Kaplan/S-1 and Linda LeyvaTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Kimberly Ramirez and Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with Stephanie Kaplan and Linda Leyva and explained the purpose of today's visit.

This home consists of (4) private client bedrooms, (2) bathrooms, living room, kitchen and dinning area.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance. Per S-1, persons coming into the facility are screened at the main building (Building #8).
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional PPE supplies are stored at Casa Colina TLC.
  • Restrooms have hand soap, hand sanitizer and paper towels.
  • Food supply (perishable for 2 days and non-perishable foods for 7 days) observed.
  • Per S-1, (C-1) only has (1) dose and has decline to receive additional COVID 19 vaccines, C-2 is fully vaccinated with the booster, C-3 and C-4 have both vaccines and no booster.
  • Per S-1, the flu vaccine is scheduled for 11/04/2022.
  • Staff responsible for direct care and supervision were wearing masks.
  • Clients were socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Stephanie Kaplan/S-1.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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