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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603491
Report Date: 01/28/2022
Date Signed: 01/28/2022 11:46:49 AM

Document Has Been Signed on 01/28/2022 11:46 AM - 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:COVENANT CARE HOMEFACILITY NUMBER:
198603491
ADMINISTRATOR:AMANYA, HERBERT BAGOROFACILITY TYPE:
735
ADDRESS:2027 SHAMWOOD STTELEPHONE:
(818) 571-2247
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 3DATE:
01/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Herbert Amanya (Administrator)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. Upon arrival, LPA met with Herbert Amanya who assisted with the visit.

An application was received on 05/19/21 for Initial License #198603491 Adult Resident Facility to serve age range 18 to 59. The requested capacity is for 4 ambulatory only.

The facility is a single story house located in a residential area which consist of a living room, 3 Client bedrooms, kitchen, dining area, 1 1/2 bathroom, shower room, laundry, attached garage/office. There is a large, covered patio area. The client bedrooms are spacious and will easily accommodate the client's furnishings. Passageways, walkways, driveway, step and patios are free of obstructions. Front, back and side areas are free of hazards, such as ladders, gardening tools, motorized equipment. Client bedroom have beds, chairs, night stands, lamps in addition to overhead lighting. There are dressers with drawers, which comply with the requirement of 8 cubic feet of space. No bedroom designated for awake-staff. Bathroom have a working toilet, wash basin and stand up showers. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review next to the main entrance. Fire Extinguisher located in the dining area mounted to the wall. Telephone system is a land line located in the kitchen. Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. Food supply adequately stored in kitchen cabinets and refrigerator. Smoke Detectors and Carbon monoxide detector are operational. Stove burners, oven, microwave, washer, and dryer working. There is one refrigerator in the kitchen. Toxins are locked and stored under the kitchen sink cabinet. Hot water temperature tested at 112.7 degrees F in the bathroom. A first aid kit has been inspected and consist the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the hallway closet available for staff use but inaccessible to clients. Continue to LIC809C.....
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: COVENANT CARE HOME
FACILITY NUMBER: 198603491
VISIT DATE: 01/28/2022
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Personnel records, Client records and Client medications are locked in a cabinet located in the living room. Applicant will be handling cash resources of clients. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff. The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. There are no Pool/Jacuzzi & Pets on the premises. Fire Clearance was granted on 10/25/21.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
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