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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603452
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:15:26 PM

Document Has Been Signed on 03/11/2025 12:15 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 CARE IIFACILITY NUMBER:
198603452
ADMINISTRATOR/
DIRECTOR:		CARTER, S'HALANAFACILITY TYPE:
735
ADDRESS:757 MILLBURY AVETELEPHONE:
(626) 257-3574
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Brandon HamptonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Nune Margaryan and Madyun Sakinah conducted an unannounced annual visit using the Care Tool. LPAs met with staff Brandon Hampton who assist with the visit. LPAs explained the reason for the visit. Administrator Carter S'Halana was informed over the phone about visit.

This is a single-story home located in a residential neighborhood and consists of the following: This home consists of (4) bedrooms, (2) bathrooms (one in the hallway and one in the master bedroom), living room, kitchen, dining area and attached garage. Laundry observed in the garage. The facility is approved for four (4) ambulatory developmentally disabled adults, ages 18-59. There are currently three (3) clients residing in this facility and receive services from San Gabriel/Pomona Regional Center.

The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded sitting area in the back of facility. Client bedrooms and bathrooms were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathrooms are clean and have the required hygiene items. The hot water temperature was tested in both bathrooms and was measured at 112.2 and 113.4 degrees F. LPAs observed that the sink in the hallway bathroom not draining the water and trash bins in the bathrooms had no lid. Extra linens, blankets, towels, and personal hygiene supplies were observed. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients. LPAs observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the hallway cabinet. 2 fire extinguishers observed in the garage and in the kitchen fully charged. Carbon monoxide/smoke detectors in the hallway / living room and in the client rooms are operational.

Continued 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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Document Has Been Signed on 03/11/2025 12:15 PM - It Cannot Be Edited


Created By: Nune Margaryan On 03/11/2025 at 11:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DHASA CARE II
FACILITY NUMBER: 198603452

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed that the sink in the hallway bathroom not draining water, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Sink was fixed at the time of visit. No further actions needed.
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed that trash bins in the bathrooms had no lid, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licnesee /Administrator will ensure all the trash bins have a lid and submit proof to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


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: DHASA CARE II
FACILITY NUMBER: 198603452
VISIT DATE: 03/11/2025
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The First Aid kit was fully stocked with all required items including a current manual. Centrally stored medications are stored in a locked cabinet in the hallway. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Observed deficiency is documented on 809D.

Exit interview conducted and the copy of the report and appeal rights are provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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