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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603528
Report Date: 02/23/2022
Date Signed: 02/23/2022 02:01:58 PM

Document Has Been Signed on 02/23/2022 02:01 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:WARVALE FACILITYFACILITY NUMBER:
198603528
ADMINISTRATOR:HERNANDEZ, YESSICAFACILITY TYPE:
735
ADDRESS:8740 WARVALE ST.TELEPHONE:
(323) 346-3450
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 4CENSUS: 0DATE:
02/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicants Yessica Hernandez & Edgar Hernandez TIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an announced visit with applicants Yessica Hernandez & Edgar Hernandez. The purpose of the visit was to conduct the Pre-Licensing visit.

An application was submitted to CCLD on 1/7/2022, for Intial License of an Adult Residential Facility. The requested capacity of 4 clients, (4) ambulatory, (0) non-ambulatory of which (0) may be bedridden.

Structure/Physical Plant:
The facility is a single story home located in a residential area and contains the following: family room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for sharps, (2) client rooms, (1) Staff room with attached bathroom. (1) bathroom for client use; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. An attached garage inaccessible to clients for storage. A washer and dryer. The residence is equipped with central air and heating.

Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: Bedrooms #1-#2 are for (2) ambulatory clients each. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: Bathroom #1 and #2 have a working toilet, wash basin, shower, and nonskid mats. Safety bars were observed in the shower and around the toilet. Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed.

Continued in LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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: WARVALE FACILITY
FACILITY NUMBER: 198603528
VISIT DATE: 02/23/2022
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Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is (1) cordless phones for client use. Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates were observed. Knives, cutlery and other sharps inaccessible to clients are kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors and Fire alarms are hardwired and connected. All tested and working. carbon monoxide detectors tested and operational. (2) Fire extinguishers observed and up to date. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured at 113 degrees throughout the facility Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to clients. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and first aid manual which is available for staff use. Clients & Staff Files: Facility has a locked cabinet for clients and staff files. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 1/31/2022.

Component III:
Component III was conducted with applicants Yessica Hernandez & Edgar Hernandez during this visit.

There are no corrections needed and the physical plant of the facility is cleared.

An exit interview was conducted over the tele-visit and a copy of this report has been furnished to Yessica Hernandez. Pre-licensing is complete and there are no deficiencies. Accordingly, LPA will submit a copy of this facility evaluation report to the Central 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: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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