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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603403
Report Date: 01/04/2024
Date Signed: 01/04/2024 03:58:43 PM

Document Has Been Signed on 01/04/2024 03:58 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:TOMINES ADULT RESIDENTIAL FACILITY IIFACILITY NUMBER:
198603403
ADMINISTRATOR:TOMINES, JONATHANFACILITY TYPE:
735
ADDRESS:613 KATHERINE DR.TELEPHONE:
(323) 246-4059
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 4CENSUS: 4DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Staff Miel TominesTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Miel Tomines and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.

LPA Trueman toured the facility along with Staff Miel Tomines today 01/04/2024 at 1:30 AM and the following was observed:
Facility contains 4 Bedrooms and 2 Bathrooms, dining room, living room, TV room, and activity room.
Required Annual Inspection included Infection Control, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/Training, Client Rights- Information, Food Service, Client Records/ Incident Reports, and Disaster Preparedness.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated.
Water temperature was checked in 2 client bathrooms and measured between 105F. and !25 F.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Carbon monoxide detector was observed in the facility.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed for 3 clients and was given per physician's directions.
4 Client Files and 7 Staff Files were reviewed.
Interviews were conducted with the 2 Staff on duty and 2 clients.

No deficiencies. Exit interview conducted and copy provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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