198603438-5-28-2021-28-AS-BTAO-C3FU49-20210528151442

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603438
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:16:41 PM

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:	NAGOMI HOME LLC		FACILITY NUMBER:	198603438
ADMINISTRATOR:	AYABE, TOKIE		FACILITY TYPE:	740
ADDRESS:	1128 N FAIRVALLEY AVE		TELEPHONE:	(626) 404-8798
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	6	CENSUS: 0	DATE:	05/28/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Tokie Ayabe, administrator /applicant Naoko Koyama, nursing manager		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA), Tao conducted a follow up announced pre-licensing inspection at the facility. The initial virtual visit was on 5/3/21. LPA met Tokie Ayabe, Licensee Applicant and staff, Koyama Naoko (LVN) at the facility. The facility has a capacity of 6. No resident was observed during the visit. LPA observed the following corrections were made: Medications, First-Aid Kit & Book: Medication cabinet is observed in administrator's office. It is installed with a lock and inaccessible to residents. First aid kit and a First Aid manual are placed in administrator's office. The kit has a thermometer, tweezers, scissors, antiseptic, bandages, and gauze. Toxins: Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. Bedrooms for Residents: Bedroom A, B, C and D have a chair. Bedroom B's ceiling hole has a ceiling light installed securely. Bedroom B's wall hole behind the door has a door magnet installed and no hole showing. Beds in Bedroom A, B and C are observed. Applicant will ensure residents to have sufficient bedding and linens after they move in. All door magnets at the facility are properly installed which are secured to the wall and has no open hole. (- Continued LIC 809 C -)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NAGOMI HOME LLC	FACILITY NUMBER: 198603438
	VISIT DATE: 05/28/2021

NARRATIVE

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Linens & Hygiene Supplies:
The required linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available and sufficient. Facility has adequate supply of linen, wash cloths and towels.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan, Exit Plan, and Labor law poster are posted near the entrance.

Food Service:
Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet under the sink in the kitchen and inaccessible to residents.
Food supply consist of two days of perishable and two weeks of non-perishable.

Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and tables and in compliance. Patio umbrellas are in place for the outdoor activity areas.
Backyard pavement is evenly paved.

Residents & Staff Files:
Locked cabinets for records of staff and clients are placed in administrative office/ nurse station.
Staff roster and Resident roster (blank forms) are available. Staff and resident folders are prepared. Applicant will update the rosters when staff are hired and residents are admitted.

Component III Presentation
Component III was conducted during this visit.

An exit interview was conducted and a copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

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