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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603463
Report Date: 08/22/2022
Date Signed: 08/22/2022 12:16:25 PM

Document Has Been Signed on 08/22/2022 12:16 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:PEPPERDALE HOMEFACILITY NUMBER:
198603463
ADMINISTRATOR:SCHAEFER, EVELINAFACILITY TYPE:
735
ADDRESS:1923 PEPPERDALE DRIVETELEPHONE:
(714) 398-4409
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 6DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Evelina Schaefer (Administrator)TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Evelina Schaefer (Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 18 through 59. Approved for 6 ambulatory only.

The facility is a single story house located in a residential area which consist of a living room/activity room, kitchen, dining area, attached garage/laundry/storage/office, 4 client bedrooms, 1 staff room and 2 bathrooms.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked. Disinfectants, cleaning solutions, poisons are inaccessible to clients. Lamps or lights in all rooms to ensure the comfort and safety were observed. Hot water temperature between 105 degrees F and 120 degrees F was measured. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Fire Extinguisher located in the kitchen is fully charged. Smoke Detectors and Carbon monoxide detector are operational. Freezers and refrigerators are clean, and maintain temperatures. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. All staff have a criminal record clearance. Staff responsible for direct care and supervision have current first aid/CPR. LPA was allowed to enter the facility to conduct the inspection. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility. All medications are labeled and maintained in compliance. Medications are safe, locked and inaccessible.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to Clarinda Roa.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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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