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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603470
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:06:47 PM

Document Has Been Signed on 04/19/2022 02:06 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:SPECIALIZED RESIDENTIAL COVINA BLVD.FACILITY NUMBER:
198603470
ADMINISTRATOR:NELSON RIVERAFACILITY TYPE:
738
ADDRESS:146 SOUTH COVINA BOULEVARDTELEPHONE:
(909) 287-3557
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 3DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Aaron Eaton; Assistant AdministratorTIME COMPLETED:
02:21 PM
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Assistant Administrator Aaron Eaton and explained the reason for the visit. Administrator Nelson Rivera was contacted via phone call during the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Assistant Administrator toured the facility and inspected (4) client bedrooms, (3) bathrooms, living room, activity room, dining room, kitchen, office/medication room, laundry room, and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 in the hallway and measured at 113F which is within the required 105F - 120F degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. Smoke detectors and carbon monoxide detectors are intertwined and were observed throughout the facility and were operable during the visit. There is a fire extinguisher located in the med room which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked and are inaccessible to clients. Cleaning supplies and disinfectants are locked in a cabinet located in the garage and are inaccessible to clients. First Aid Kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff were observed wearing masks and screening visitors at entry.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (3) out of the (3) client medications were reviewed. Medications are centrally stored in a cabinet located in the med room. Medications are documented properly and given as prescribed.
  • Staff and Client files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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