198603465-9-17-2021-28-AS-BTAO-C6XPGE-20210917111812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603465
Report Date: 09/17/2021
Date Signed: 09/17/2021 11:18:31 AM

Document Has Been Signed on 09/17/2021 11:18 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	NAZARENE HOME CARE		FACILITY NUMBER:	198603465
ADMINISTRATOR:	RODRIGUEZ, ULYSIS		FACILITY TYPE:	735
ADDRESS:	1709 E WINGATE STREET		TELEPHONE:	(909) 967-6966
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY: 4		CENSUS: 0	DATE:	09/17/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ulysis Rodriguez, administrator Gemma Rodriguez, applicant		TIME COMPLETED:	11:30 AM

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) Tao conducted an announced pre-licensing inspection. LPA met with Gemma Rodriguez, applicant, and Ulysis Rodriguez, administrator. This is a new application applying for Adult Residential Facility to serve for ages 18 to 59 years. The requested capacity is four (4) clients. The facility is located in a residential neighborhood. Administrator certificate is current and expiration date is 10/01/2022. Fire clearance: Its fire clearance is approved for three (3) ambulatory clients and one (1) non-ambulatory client. Bedroom #4 is for non-ambulatory client. This facility is granted a fire clearance on July 29, 2021. Structure: The facility is a single-family house. There are four (4) client bedrooms, two (2) bathrooms, kitchen, dining area near the kitchen, living room with a TV, laundry room, and backyard with a patio. Bedrooms for clients: Bedrooms have a nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. Bedroom #4 for ambulatory clients are accommodated Bathrooms: Toilet, wash basin, and shower in bathroom are operable. Grab bars are maintained for bathtub. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Stove is operable. Water temperature tested at 115.5 degrees Fahrenheit in kitchen sink which was in compliance with the regulation. (-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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: NAZARENE HOME CARE	FACILITY NUMBER: 198603465
	VISIT DATE: 09/17/2021

NARRATIVE

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Smoke Detectors:
Five (5) smoke detectors and two (2) carbon monoxide detectors located in hallways and each room. They are operational and not hard wired.

Appliances:
Stove burners, oven, microwave, washer, and dryer are working. Refrigerator in the kitchen and has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Linens & Hygiene Supplies:
The required linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are sufficient. Adequate supply of linen, wash cloths and towels are observed.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan is posted near the entrance. Emergency phone numbers, exit plan, Covid signages and posters are posted.

Food Service:
Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer in the kitchen and inaccessible to clients. Food supply is sufficient. The food supply consists of two days of perishable and two weeks of non-perishable.

Medications, First-Aid Kit & Book:
Medication cabinet is locked and inaccessible to clients. First aid kit is fully stock with a First Aid manual from American red cross.

Menu and phone:
Menus are available for review.
Free landline telephone is available for clients’ use and operable.

(-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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: NAZARENE HOME CARE	FACILITY NUMBER: 198603465
	VISIT DATE: 09/17/2021

NARRATIVE

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Fire extinguishers:
One fire extinguisher is located in the kitchen which is mounted on wall. Another fire extinguisher is located in the garage. They are fully charged. The last service is done on July 29, 2021.

Clients & Staff Files:
Applicant will be handling cash resources of clients and has a surety bond. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients are stored in a locked cabinet and the section has been inspected along with the available records at the locked cabinet.

Reading Material, Games, Equipment & Materials:
The facility has recreational materials available for clients’ use and commensurate with the plan of operation.
Pool:
No bodies of water located at the facility.

Outdoor activity area in backyard:

Outdoor activity area is furnished with chairs and table, located under a shaded area and in compliance with the regulation.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to clients.

No issue is observed during the visit.

Exit:

Component III was conducted during this visit.

An exit interview was conducted and a copy of this report was provided to applicant. 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, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC809 (FAS) - (06/04)

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