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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603546
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:10:36 PM

Document Has Been Signed on 04/28/2022 02:10 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:PACIFIC HORIZON VFACILITY NUMBER:
198603546
ADMINISTRATOR:KIM, JENNIFERFACILITY TYPE:
735
ADDRESS:341 N MAPLE AVETELEPHONE:
(562) 368-1479
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 6CENSUS: 0DATE:
04/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jennifer KimTIME COMPLETED:
12:00 PM
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Licensing Program Analyst's (LPA's) Glenn Trueman, Ashley Calderon, and Valeria Maldonado made an announced visit and was greeted by Administrator Jennifer Kim, Vice President Michael Kim and Assistant Administrator Mylene Bumanlag and explained the reason for the visit.
The purpose of the visit is to conduct the pre licensing visit.
LPA's toured the facility today 04/28/2022 at 9:45 AM and the following was observed:
Facility contains 4 Client Bedrooms and 2 Bathrooms, dining room, living room, TV room, and activity room.
Locked storage area for central storage of medications is available.
Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair.
Locked storage area for poisons, toxic, cleaning solutions, and disinfectants.
Doors, stairways, and passageways are unobstructed.
An emergency exiting plan and emergency phone numbers posted in an appropriate place.
An operating telephone on the premises and available to clients.
First aid supplies, which include sterile first aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first aid manual is maintained.
Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly.
Furniture is room/client appropriate, clean and in good repair.
Each client has an adult bed with mattress, pad, bedsprings, and pillow, which are clean and in good repair.
Each client has an adequate dresser and closet space for clothing and other belongings that includes at least 2 drawers or 8 cubic feet of dresser space.
A sufficient supply of linens to permit weekly changing or more often to insure clean linen at all times for clients. Equipment and supplies for client personal hygiene is available and on site.
Hot water temperature measured 117 F. in both client restrooms meeting Title 22 Regulations.
Physical Plant met Title 22 requirements. Component 3 conducted at today's visit.
Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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