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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603474
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:01:39 PM

Document Has Been Signed on 09/14/2022 12:01 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: 4DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Connie MitchellTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Connie Mitchell and discussed the purpose of today's visit.

This home consists of: (4) bedrooms, (2) bathroom, office, living room, kitchen with dinning area and an attached garage.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and the dinning area.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional PPE supplies are stored inside the garage.
  • Hygiene supplies observed. Additional hygiene supplies are stored inside the garage.
  • Bathrooms have hand soap, paper towels and hand washing signs.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. An additional refrigerator and canned goods were observed inside the garage.
  • Medication reviewed for Client #1 through Client #4 (C-1 through C-4).
  • Staff responsible for direct care and supervision will continue wearing masks.


Exit interview conducted, a copy of this report and Appeal Rights were provided to Connie Mitchell
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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