198603448-1-4-2022-28-AS-CWOG-CACTML-20220104135120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603448
Report Date: 01/04/2022
Date Signed: 01/04/2022 01:51:33 PM

Document Has Been Signed on 01/04/2022 01:51 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:	PEOPLE'S CARE FELLOWSHIP		FACILITY NUMBER:	198603448
ADMINISTRATOR:	FLORES, DENISE		FACILITY TYPE:	735
ADDRESS:	15762 FELLOWSHIP STREET		TELEPHONE:	(909) 287-3557
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY: 4		CENSUS: 0	DATE:	01/04/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:43 PM
MET WITH:	Cristin Nicoletti-Project Manager		TIME COMPLETED:	02:00 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 Analyst (LPA), Christine Wong, conducted an announced visit to the facility for purpose of a prelicensing evaluation. With the present of Cristin Nicoletti, Project Manger and Jose Mendoza, Districtg Manger. An application was submitted to CCLD on 01/21/2021, for Initial license for a Adult Residential Facility to serve age range 18 through 59. The requested capacity is for 3 ambulatory and 1 non-ambulatory. Structure: The facility is a single story house and located in a residential neighborhood area. Facility is a 4 bedrooms, 2 bathrooms, kitchen, living room, staff office, dining area and client's computer area. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a huge back yard with a covered and shaded area for table and chairs. The passageways, walkways, driveway are free from obstructions. The front, back and side areas of free of hazards and maintained in a good condition. Signal system: The facility has a delayed egress with key and code to enter into the facility and LPA observed and its operational Bedrooms Residents: There is one bed in each client's bedroom. Bedroom# 4 is for non-ambulatory clients. Each bedroom has one beds, one chairs, one night stand, one dresser, one closet and overhead lighting. Bathrooms: All bathrooms have a working toilet, wash basin and shower. There is bathroom#1 that will accommodate non-ambulatory clients in a wheel chair.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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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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: PEOPLE'S CARE FELLOWSHIP	FACILITY NUMBER: 198603448
	VISIT DATE: 01/04/2022

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in client's closet and the personal hygiene supplies will be stored and locked in the file cabinet in the living room.

Emergency Phone Numbers, Exit Plan & Menu:
The facility has a landline phone # and the phone number is 626-461-7751.
Posted & readily available for review in staff office near the dining area. Fire Extinguisher located in the kitchen mounted on wall

Food Service:
Dishes, cups and flat ware are stored in the kitchen cabinets, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored and locked in a kitchen cabinet. Food supply adequate stored in the kitchen and consists of the following: 2 days perishable and 7 days non-perishable.

Smoke Detectors
The smoke detector is electrical & inter-connected. Its located in each bedroom and common area. The Carbon monoxide detector located in living room and dining area and is operational.

Appliances:
Stove burners, oven, microwave, washer, and dryer working properly. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The client's bedroom is equipped with central air and heat.

Toxins:
All cleaning supplies and toxins are locked and stored under the sink and laundry room.

Water Temperature:
The hot water temperature in bathroom#1 and #2 and kitchen and was tested at 111 and 115 degrees F.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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: PEOPLE'S CARE FELLOWSHIP	FACILITY NUMBER: 198603448
	VISIT DATE: 01/04/2022

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Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored and locked in a kitchen cabinet, available for staff use but inaccessible to clients. Clients' medication is centrally stored and locked in the cabinet in the laundry room.

Clients & Staff Files:
Applicant will be handling cash resources of clients and has a surety bond for $3000, cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked file cabinet in the living room. The client and staff files are stored and locked in the file cabinet in the living room.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use and they are located in the living room.

Fire clearance:
Fire Clearance with bedroom#1 to #4 are okay for non-ambulatory and the delayed egress also granted and they were all approved on 10/26/21.

Component III:
It was Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, 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, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC809 (FAS) - (06/04)

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