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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603460
Report Date: 06/07/2022
Date Signed: 06/07/2022 06:44:36 PM

Document Has Been Signed on 06/07/2022 06:44 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:ST. SHARBEL'S GARVEYFACILITY NUMBER:
198603460
ADMINISTRATOR:MUNZON, PETERFACILITY TYPE:
735
ADDRESS:2007 E GARVEY AVE NTELEPHONE:
(562) 682-7027
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 4DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Peter Munzon-Administrator TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with DSP Crisbo Langa and explained the reason for the visit and also assisted LPA with the tour of the facility. Shortly after, the administrator Peter Munzon arrived. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in the residential neighborhood. The facility included living room, dining room, kitchen, 3 client bedrooms, 2 and half bathrooms and staff office/break room and a detached garage. All 3 clients bedrooms were toured. All client's bedrooms has two beds, two drawers, two night stand and required bed linen, furniture and sufficient lighting and closet space. All two and half bathrooms were toured and they are clean, sanitary and in a operable condition. The hot water temperature in two and half bathrooms were measured between 105.7 and 111.6 degrees F which is within the Title 22 regulation. The food in the refrigerator, pantry and garage are sufficient for 2 days perishable and 7 days non-perishable. The sharp knives are locked in the kitchen cabinet. All the appliance in the kitchen are working properly. The toxic and cleaning supplies are locked in the garage which is inaccessible to the clients. The common area such as living room and dining room are clean and have the required furniture. The front and back yard are maintained well. LPA also inspected the carbon monoxide detectors and smoke detectors and they are located in each bedroom and common area and they are working well.

LPA reviewed all 4 client files to confirm emergency contact is updated. LPA also reviewed 3 staff files to confirm health screenings and fingerprint clearances and they are all fingerprint cleared and the health screening forms are updated in the file. LPA reviewed all 4 clients' medications and all clients' medication are accurate and updated.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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: ST. SHARBEL'S GARVEY
FACILITY NUMBER: 198603460
VISIT DATE: 06/07/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each room and facility is disinfected every shift, the bathrooms have sufficient soap, paper towels, and signs, facility has sufficient PPE supplies for more than 30 days.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to administrator Peter Munzon.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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