<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603509
Report Date: 04/06/2022
Date Signed: 04/06/2022 12:40:36 PM

Document Has Been Signed on 04/06/2022 12:40 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:ABS FILMORE RESIDENTIALFACILITY NUMBER:
198603509
ADMINISTRATOR:ROJAS, DIANAFACILITY TYPE:
735
ADDRESS:658 FILMORE PLTELEPHONE:
(909) 455-8159
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 0DATE:
04/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ApplicantTIME COMPLETED:
01:00 PM
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) Elizabeth Irra conducted this visit to conduct the pre-licensing. LPAs met with Applicant, Diana Rojas.

The facility is to serve (4) ambulatory individuals age 18 through 59 years old. This home consists of (3) bedrooms, (2) bathrooms, living room, kitchen and dining area. Component III was also completed during this visit.

The following was observed/inspected
  • Smoke detectors operate properly.
  • Carbon monoxide detector was tested and operable. Located in the living room
  • Fire extinguisher located in the entrance/kitchen. Located near the front door and in the living room.
  • Cleaning solutions and sharps are locked.
  • 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.
  • Sufficient amount of personal hygiene supplies are available for clients.
  • Sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by clients.
  • Facility has a washer and dryer that are fully operational located outside in the back of the home.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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: ABS FILMORE RESIDENTIAL
FACILITY NUMBER: 198603509
VISIT DATE: 04/06/2022
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
26
27
28
29
30
31
32
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two day supply of perishables available, seven day supply of non-perishable available.
  • The facility has sufficient dining tables and chairs.
  • Pesticides and other toxic substances are stored and locked away from food supply.
  • There is a designated space for Medications to be locked.
  • Client and Staff files will be stored and locked in designated file cabinet.
  • First Aid Kits observed.
  • Physical plant is in good repair.
  • Building and grounds are free from hazards.
  • Window screens are in good condition.
  • Shaded area is set up in the backyard to accommodate 4 clients.
  • Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly.
  • Hot water temperature measured at 118.0*.

Exit interview conducted, copy of report provided to Diana Rojas (Applicant).
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2