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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603467
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:24:49 PM

Document Has Been Signed on 05/19/2023 01:24 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:PEOPLE'S CARE LOMITASFACILITY NUMBER:
198603467
ADMINISTRATOR:JILLIAN FLORESFACILITY TYPE:
738
ADDRESS:14055 LOMITAS AVENUETELEPHONE:
(909) 287-3557
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 3DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff / Emerie Alailefaleula
Assistant Administrator / Fiona Mutu
Administrator / Jillian Flores		TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. Upon arriving at the facility, LPA met with Staff /Emerie Alailefaleula and was later joined by the Administrator / Jillian Flores and Assistant Administrator / Fiona Mutu, who assisted with the visit. LPA explained the purpose of this visit. There are three (3) ambulatory developmentally disabled clients residing at the facility. The facility is licensed as an Adult Residential Facility (ARF) for clients who are between the ages of 18 through 59, vendored by San Gabriel/Pomona Regional Center (SGPRC).

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility is encouraging hand washing and self symptom check of staff and visitors. Each client bedroom is designated as a COVID-19 isolation room if needed and will use the closest restroom. The facility has an Infection Control Plan.

Physical Plant/Environment Safety:
  • The facility is located in a residential neighborhood in the city of La Puente and is a one story building which consists of four (4) client bedrooms, two (2) bathrooms, living room, activity room, dining room, kitchen, office, laundry room, and detached garage. The facility has a fire clearance from the local Fire Department for a capacity of four (4) non-ambulatory clients ages 18 - 59, approved for delayed egress on perimeter exterior.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: PEOPLE'S CARE LOMITAS
FACILITY NUMBER: 198603467
VISIT DATE: 05/19/2023
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  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has three (3) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings were measured between the required 105 - 120 degrees Fahrenheit.

Operational Requirements:
  • The Program Design was reviewed.
  • Fire clearance was approved by LA County Fire Department for four (4) non-ambulatory clients ages 18 - 59, approved for delayed egress on perimeter exterior.
  • Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients.
  • Current Surety bond was reviewed and is current.

Staffing:
  • A total of forty six staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 12/3/2023.
  • A random selection of staff files were reviewed for criminal background clearance and training.
  • Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • A random selection of client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication administration records, and P & I monies were
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: PEOPLE'S CARE LOMITAS
FACILITY NUMBER: 198603467
VISIT DATE: 05/19/2023
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reviewed.

Food Service:

  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • Physician orders for modified diets are in place.

Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • A random selection of client medication records were reviewed. Centrally stored medications are kept in the office cabinet and kept locked and inaccessible to clients in care. Medications are given according to Physician directions.

Incident Medical and Dental:
  • All clients have a Needs and Services Plan and COVID-19 vaccination cards on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.
  • An emergency drill was conducted on 4/30/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.


No deficiencies were observed during this visit.

An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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