198603499-10-18-2021-28-AS-CWOG-C7WNSL-20211018104318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603499
Report Date: 10/18/2021
Date Signed: 10/18/2021 10:43:29 AM

Document Has Been Signed on 10/18/2021 10:43 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:	SPOELSTRA LLC DBA VOICE LA PUENTE		FACILITY NUMBER:	198603499
ADMINISTRATOR:	STOCK, PATRICIA		FACILITY TYPE:	775
ADDRESS:	13907 "D" E AMAR ROAD		TELEPHONE:	(909) 792-2428
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY: 100		CENSUS: 20	DATE:	10/18/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Patricia Stock -Program Director		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA)Christine Wong, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to CCLD on 06/18/2021 for a name change for Adult Day Program. The requested capacity is for 100 ambulatory and non-ambulatory clients. Structure: Facility consists of two side of the building. On the North side, it includes the reception area, Program Director office, Educational Equipment/Main Room, Pre-Vocational and Health Living Room, LVN office/Treatment room for client to rest, Program Director Assistant office, General Store, Life Skills Room, Clients lockers, two changing rooms, storage room and kitchen. For the South side, it includes Transportation room, Staff Lockers room, Arts expression room, Changing room, Current Event Room and a little kitchen. There's also a patio with tables and chairs for clients to use. The passageways and walkways are free of obstruction. All the front, back and side areas are free of hazards. Bathrooms: On the North side, Men Restrooms are included four single toilet, one for handicapped with grab bars, one shower, two urinal and three sinks. For the women restrooms are included five toilet, one for handicapped with grab bars, two sinks and one shower. There's also one unisex bathroom in the LVN office with one toilet and one sink. On South side, there's one unisex bathroom with one toilet and one sink. All bathrooms have a working toilet, wash basin, shower and they are able to accommodate for non-ambulatory clients in a wheel chair. Emergency Phone Numbers, Exit Plan The facilities telephone system is a landline. Posted & readily available for review in the Reception area. Fire Extinguisher located around the facility area.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

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: SPOELSTRA LLC DBA VOICE LA PUENTE	FACILITY NUMBER: 198603499
	VISIT DATE: 10/18/2021

NARRATIVE

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Food Service:
Client brings their own food which the facility will re -heat and receive snacks at the Program.

Smoke Detectors:
Electrical & connected. Carbon monoxide detector located in Changing room and is operational.

Toxins:
All the disinfectants, cleaning solutions, and poisons are inaccessible to clients and they are all located in the storage room in the North Side.

Water Temperature:
The hot water tested at the bathroom in LVN office, Men and Women Bathrooms are between 120.4 and 133.1 degrees F.

Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored all around the facility, available for staff use but inaccessible to clients. Medication is locked in the LVN office and inaccessible to client's.

Clients & Staff Files:
All the records of staff and clients shall be stored in a locked cabinet in the program director office.

Fire clearance:
Fire Clearance was approved on 08/11/2021

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

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

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: SPOELSTRA LLC DBA VOICE LA PUENTE	FACILITY NUMBER: 198603499
	VISIT DATE: 10/18/2021

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During the pre-licensing inspection, it was observed which do not comply with applicable laws and regulations; the following item must be corrected and proof of correction which included self certified written statement with picture shall be submitted to the CCLD office to the attention of LPA by 10/25/21 . If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date.

1. The hot water temperature in the bathroom of LVN office, Men and Women Bathroom are over 120 degrees F.

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 Centralized Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

LIC809 (FAS) - (06/04)

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