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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603465
Report Date: 10/29/2024
Date Signed: 10/29/2024 05:16:58 PM

Document Has Been Signed on 10/29/2024 05:16 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:NAZARENE HOME CAREFACILITY NUMBER:
198603465
ADMINISTRATOR/
DIRECTOR:
RODRIGUEZ, ULYSISFACILITY TYPE:
735
ADDRESS:1709 E WINGATE STREETTELEPHONE:
(909) 967-6966
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 0DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Staff#1, staff in chargeTIME VISIT/
INSPECTION 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). LPA met Staff#1 (S1), staff in charge, who assisted with the visit. LPA discussed the purpose of today's visit with Administrator Gemma over the phone.

This annual visit included staff interview with staff, used of CARE inspection tool, physical plant, and food supply/staff records review. Since no client residing at the facility, client files and medication were not reviewed. Per the phone conversation, Administrator explained regional center is working on vendorizing clients to the facility.

The home was a single family home, located at a residential neighborhood in the city of Covina, consisted 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 was clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms/ bathrooms were furnished with required furniture and in compliance. Adequate linen and personal hygiene supply are observed. Smoke detectors and carbon monoxide detectors were operable. Hot water temperature measured at 113.5 degrees Fahrenheit. Medication cabinet with locks were located in the kitchen and centrally stored. 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 staff#1, staff in charge.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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