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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603470
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:16:53 PM

Document Has Been Signed on 04/11/2023 03:16 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
GREATER LA AC/SC, 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: 2DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Daniel Acevedo, Administrator TIME COMPLETED:
03:29 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an annual required visit. LPA met with Administrator, Daniel Acevedo and explained the reason for the visit. The facility cares for adults with developmental disabilities and is vendorized by San Gabriel/Pomona, RCOC and North Los Angeles Regional Centers. The home 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.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection control plan at facility
Physical Plant & Environment Safety: . There are (4) client bedrooms, three (3) bathrooms, living room, activity room, dining room, kitchen, office area, laundry room, and attached garage. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathroom and kitchen were measured between 105.2 – 117.3 degrees F which are within the required range of 105-120 degrees F.
Operational Requirements The licensee provides care and supervision as required. Has fire clearance and documentation of required training

(Continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPECIALIZED RESIDENTIAL COVINA BLVD.
FACILITY NUMBER: 198603470
VISIT DATE: 04/11/2023
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Staffing: There appears to be sufficient staffing at the facility. The administrator’s Daniel Acevedo certificate expires 5/20/23 Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR first aid training and sufficient on-going training. Facility has documentation on file that verify lead staff qualifications.
Client’s Records-Information: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, pre-admission IPP and other required documentation.
Client’s Rights-Information: The Complaint poster and client’s personal rights are posted at facility. Visiting hours are not posted as visitors are permitted 24 hours a day depending on client’s choice.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week (7 days) of non-perishable items. The food is properly stored in the refrigerator to avoid cross contamination.
Health Related Services: Clients are assisted with medication administration and dental and medical appointments including transportation.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 2 client’s medication and medication is administered following physician’s orders.
Disaster Preparedness: The facility does have an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency drill was conducted March 3rd 2023
Emergency Intervention The facility accepts and retains clients with developmental disabilities and is vendorized by San Gabriel/Pomona, RCOC and North Los Angeles Regional center. The staff received training on appropriately caring for residents with developmental disabilities and emergency intervention.

During the visit today, LPA did not observed deficiencies at time of visit. Technical advisories were provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to Administrator Daniel Acevedo
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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