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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603474
Report Date: 09/02/2021
Date Signed: 09/02/2021 03:30:41 PM

Document Has Been Signed on 09/02/2021 03:30 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:HELIOFACILITY NUMBER:
198603474
ADMINISTRATOR:MARCELO, TAJFACILITY TYPE:
735
ADDRESS:510 FOXPARK DRIVETELEPHONE:
(929) 429-0836
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 0DATE:
09/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Applicant TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a pre-licensing visit and met with Applicant. This facility is to serve 4 ambulatory individuals age 18 through 59 years old. Component III was also completed during this visit.

The following was observed/inspected:

  • Smoke detectors operate properly.
  • Carbon monoxide detector was tested and operable. It is located near hallway near the bedrooms.
  • Fire extinguisher located in the kitchen and garage. Service date: 03/13/21.
  • Cleaning solutions are locked inside a hallway closet and in the garage. Sharps are locked under the kitchen.
  • Building and grounds are free from hazards.
  • Physical plant is in good repair.
  • Beds have the required linen/supplies.
  • Mattresses and bedsprings are in good repair.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
  • Clients have the appropriate furniture (one chair, night stand, adequate lighting for each client adequate closet and drawer space).
  • There are enough bath towels, hand towels and wash cloths for all clients.
  • There are sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by clients. There are extra supplies inside each bedroom.
  • Facility has a washer and dryer that are fully operational located inside the garage.
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.

***Refer to LIC 809C for the continuation of this report***
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HELIO
FACILITY NUMBER: 198603474
VISIT DATE: 09/02/2021
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  • Two day supply of perishables available, seven day supply of non-perishable available. Additional emergency food and water supply are stored inside the garage.
  • The facility has sufficient dinning tables and chairs.
  • Pesticides and other toxic substances are stored and locked inside the laundry room cabinet.
  • Client files (including P&I) and staff files will be locked inside a cabinet in the office area. Medication will also be stored and locked inside the a cabinet in the office area as well.
  • First Aid Kit inspected. American Heart Associated First Aid Manual observed.
  • Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly.
  • Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly.
  • Hot water temperature measured at 113.5* in the kitchen sink and all bathrooms.
  • Personal rights, Emergency Disaster Plan, Complaint Procedures are posted.
  • COVID-19 signs are posted throughout the facility including the entry door.

Pre-Licensing is complete. Applicant to contact assigned CAB Analyst to further discuss floor plan involving bedroom #4.

Exit interview conducted, copy of report provided to Applicant

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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