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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603424
Report Date: 05/27/2022
Date Signed: 05/27/2022 11:45:22 AM

Document Has Been Signed on 05/27/2022 11:45 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NEW HOPE HOME CAREFACILITY NUMBER:
198603424
ADMINISTRATOR:MANZANO, CARMENCITAFACILITY TYPE:
735
ADDRESS:2146 VIRGINIA AVE.TELEPHONE:
(909) 306-7757
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 1DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:S-1TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and explained the purpose of today's visit.

This is a single story home that consists of: (5) bedrooms, (3) bathrooms, living room, kitchen, dinning room, family room and an attached garage. The laundry unit is set-up near the kitchen.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices signs were posted throughout the facility.
  • PPE supplies observed at the entrance. Additional PPE supplies are stored inside the hallway closet.
  • Hand sanitizer and sanitizer wipes observed throughout the facility.
  • Hygiene supplies observed. Additional supplies are stored inside the hallway closet.
  • Incontinence supplies observed. Additional supplies are stored inside the hallway closet.
  • Restrooms have hand soap, hand sanitizer and have paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Emergency food supply was stored inside the hallway closet.
  • Per S-1, C-1 is fully vaccinated including the booster.
  • Per S-1, all (3) staff are fully vaccinated including the booster.
  • Client medication supply reviewed.


Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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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