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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603452
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:51:51 AM

Document Has Been Signed on 02/10/2023 11:51 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DHASA CARE IIFACILITY NUMBER:
198603452
ADMINISTRATOR:CARTER, S'HALANAFACILITY TYPE:
735
ADDRESS:757 MILLBURY AVETELEPHONE:
(773) 718-0819
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 2DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:S'halana Carter TIME COMPLETED:
11:15 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'halana Carter and discussed the purpose of today's visit.

This home consists of (4) bedrooms, (2) bathrooms, living room, kitchen, dinning area and attached garage. Each client has their own bedroom. All 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.
  • PPE supplies observed.
  • Hygiene supplies observed.
  • Restrooms have hand soap and paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Medication reviewed for (2) Clients (C-1 through C-2).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients socially distance according to local public health guidelines.


Exit interview conducted, a copy of this report and Appeal Rights were provided to S'halana Carter.

Note; LPA was experiencing technical difficulties during today's visit.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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