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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603443
Report Date: 03/16/2022
Date Signed: 04/21/2022 08:02:22 PM

Document Has Been Signed on 04/21/2022 08:02 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:DHASA CAREFACILITY NUMBER:
198603443
ADMINISTRATOR:DEBELA-SLEDGE, HURUBEFACILITY TYPE:
735
ADDRESS:2181 LARCHMONT STTELEPHONE:
(773) 718-0819
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
03/16/2022
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/Facility Administrator and explained the purpose of today's visit.

This is a single story home that consists of: (4) private bedrooms, (2) bathrooms (one bathroom is located inside a client bedroom), living room, kitchen, dinning room, activity room and an attached garage. The laundry unit is set-up inside the garage.

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.
  • PPE and hygiene supplies observed. Additional, hygiene supplies are stored inside a locked garage cabinet.
  • Bathroom has hand soap and hand sanitizer.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional freezer with food supply observed inside the garage.
  • Per Administrator, Client #1 through Client #3 (C-1 through C-3) clients are vaccinated. Client #4 (C-4) refuses to get the vaccine(s).
  • Medication reviewed for Client #1 through Client #4. Medication is stored and locked inside a kitchen cabinet.
  • Per Administrator, all staff are fully vaccinated including booster.
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1/Facility Administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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