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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603470
Report Date: 04/12/2024
Date Signed: 04/12/2024 03:25:51 PM

Document Has Been Signed on 04/12/2024 03:25 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SPECIALIZED RESIDENTIAL COVINA BLVD.FACILITY NUMBER:
198603470
ADMINISTRATOR/
DIRECTOR:		DANIEL ACEVEDOFACILITY TYPE:
738
ADDRESS:146 SOUTH COVINA BOULEVARDTELEPHONE:
(626) 474-2195
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 3DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Alexandria Moreno- House LeadTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Sanjay Vaid conducted an annual required visit. LPA met with AM House lead, Alexandria Moreno 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.

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. 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 107.2 – 115.3 degrees F which are within the required range of 105-120 degrees F.
Staff files are maintained at the facility. Staff have current CPR first aid training and on-going training. Facility has documentation on file that verify staff qualifications.
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.
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.

CON'T ON 9099 C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPECIALIZED RESIDENTIAL COVINA BLVD.
FACILITY NUMBER: 198603470
VISIT DATE: 04/12/2024
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Clients are assisted with medication administration and dental and medical appointments including transportation.
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. The facility does have an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency drills were conducted in March, fire drill 3/13/2024, earthquake drill 3/27/2024, flood drill 03/20/2024.

During the visit today, LPA did not observed deficiencies at time of visit. An exit interview was held. A copy of this report was given to PM House lead Teshoma Itsuokor.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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