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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603546
Report Date: 05/25/2023
Date Signed: 05/25/2023 11:52:16 AM

Document Has Been Signed on 05/25/2023 11:52 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:PACIFIC HORIZON VFACILITY NUMBER:
198603546
ADMINISTRATOR:KIM, JENNIFERFACILITY TYPE:
735
ADDRESS:341 N MAPLE AVETELEPHONE:
(323) 516-6097
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 6CENSUS: 4DATE:
05/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff Joyceline AbrenicaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Joyceline Abrenica and explained the reason for the visit. The purpose of the visit is to complete the required inspection. Shortly thereafter Administrator Jennifer Kim arrived.
LPA Trueman toured the facility along with Staff Joyceline Abrenica today 05/25/2023 at 9:10 AM and the following was observed:
Facility contains 4 Client Bedrooms and 2 Client Bathrooms, dining room, living room, TV room, and outdoor backyard shaded area.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.
Interviews were conducted with 2 clients and 2 staff. 4 client files and 3 staff files were reviewed
All staff were cleared and associated.
Medication was administered per physician's directions.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Staff responsible for providing care and supervision received training in First Aid.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.

No deficiencies.

Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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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