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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603465
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:54:56 PM

Document Has Been Signed on 10/14/2022 04:54 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:NAZARENE HOME CAREFACILITY NUMBER:
198603465
ADMINISTRATOR:RODRIGUEZ, ULYSISFACILITY TYPE:
735
ADDRESS:1709 E WINGATE STREETTELEPHONE:
(909) 967-6966
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 0DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Gemma Rodriguez, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection. The facility is licensed as Adult Residential Facility to serve for ages 18 to 59 years old, four (4) ambulatory clients, of which one (1) maybe non-ambulatory. Client census is zero (0). Annual fee is current. LPA met Gemma Rodriguez, Administrator, who assisted with the visit. LPA discussed with Administrator about the purpose of today's visit.

During the visit, the following domain of the new inspection tool was used: infection control domain and staff interview; Besides, staff file was reviewed; a tour of the facility was conducted; and food supply was reviewed. Since client census was zero, LPA did not conduct client interview, medication review and client file review.

LPA toured the facility inside and outside. The home is located in a residential neighborhood within the city of Covina and is a one story building which consists of 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. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. All burners and stove tops were in working condition. Clients’ bedrooms have beds, dressers, chairs and closet space available. Adequate linen and personal hygiene supply are observed. Bathrooms are clean and operational.

LPA also inspected facility common areas including the kitchen, living room, and dining room. Administrator tested the smoke detectors and carbon monoxide detectors were operable. Fire extinguisher was fully charged. Comfortable temperature of 73 degree Fahrenheit for clients was maintained. Hot water temperature measured at 109.5 degrees Fahrenheit. Client beds were in good condition and had appropriate linens. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. (-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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: NAZARENE HOME CARE
FACILITY NUMBER: 198603465
VISIT DATE: 10/14/2022
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Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

Medications were centrally stored, locked in a cabinet located in the kitchen. Medications were properly logged and current. Hazardous items were locked and inaccessible to clients.

No deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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