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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603430
Report Date: 05/13/2022
Date Signed: 05/13/2022 12:45:17 PM

Document Has Been Signed on 05/13/2022 12:45 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:GLADSTONE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603430
ADMINISTRATOR:TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:3008 GLADSTONE ST.TELEPHONE:
(909) 392-2973
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:S-1TIME COMPLETED:
12:30 PM
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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 home with 4 bedrooms, 2 bathrooms, living room, kitchen, dinning area with an attached garage. All (3) clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed. Hand washing signs also posted inside the bathrooms.
  • PPE supplies observed. Additional PPE supplies stored inside the attached garage.
  • Hygiene supplies observed. Additional supplies stored inside the hallway closet.
  • Incontinence supplies observed inside the attached garage.
  • Restrooms have hand soap, hand sanitizer and paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supplied stored inside the attached garage.
  • Medication reviewed for (3) Clients (Client #1 through Client #3)
  • Per S-1, (3) clients and staff are fully vaccinated including the Booster.
  • Per S-1, (4) staff are fully vaccinated. Boosters are pending. .
  • Staff responsible for direct care and supervision will wear masks.

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: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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