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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603531
Report Date: 07/26/2024
Date Signed: 07/26/2024 04:33:39 PM

Document Has Been Signed on 07/26/2024 04:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAIR OAKS MANORFACILITY NUMBER:
198603531
ADMINISTRATOR/
DIRECTOR:
ALMERO, CARMENFACILITY TYPE:
735
ADDRESS:1753 N. FAIR OAKS AVE.TELEPHONE:
(626) 345-9788
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 14CENSUS: 12DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH: Maria Liliosa Franco - Direct Care Staff
Simplicia Gabia-Demoica - Direct Care Staff
TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Maria Liliosa Franco, Direct Care Staff and Simplicia Gabia-Demoica, Direct Care Staff and explained the purpose of the visit. At 2:47pm, LPA spoke with Administrator Marycel Campos on the phone and stated that she will not be able to be in the facility to assist with the inspection. The facility is licensed to care for (14) Developmentally Disabled Adults, ambulatory, of which (2) may be non-ambulatory, ages 18 through 59. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. The facility is a level 2. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Staff are adhering to infection control requirements.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection.***

No deficiencies observed during the time of this visit. Exit interview conducted with Maria Liliosa Franco, Direct Care Staff and a copy of this report has been provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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