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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603553
Report Date: 06/29/2023
Date Signed: 06/29/2023 10:44:48 AM


Document Has Been Signed on 06/29/2023 10:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:TIMERS RESIDENTIAL CAREFACILITY NUMBER:
198603553
ADMINISTRATOR:WILLIAMS, SHAUNDAFACILITY TYPE:
740
ADDRESS:452 PEMBROOK AVENUETELEPHONE:
(424) 457-9771
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY:6CENSUS: 0DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shaunda Williams/AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Shaunda Williams (Administrator) and discussed the purpose of today’s visit. Per Ms. Williams,there has not been any admissions since becoming licensed. Administrator will adhere by the Care Tool requirements prior to accepting the first resident. LPA provided guidance to Ms. Williams on where to retrieve the Care Tool on-line. The facility is to serve 6 ambulatory individuals over the age of 60. This is a 2 story home which consist of (3) bedrooms, (2) baths, living room, kitchen, dining area, office (upstairs) and an attached garage with the laundry unit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control Plan in place.
Operational Requirements: The fire clearance is approved for (6) ambulatory.
Staffing: Administrator Certificate for Shaunda Williams on file expires on 10/26/23.
Personnel Records-Training: First Aid/CPR certification for Shaunda Williams expires on 03/11/24.
Resident Rights-Information: Resident rights are posted.
Resident Records-Incident Reports: No residents have been admitted since licensure.
Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place.
Physical Plant & Environment Safety Carbon Monoxide and Smoke Alarms observed. Fire Extinguisher appears to be full. Facility is maintained cleaned and organized.
Planned Activities: No residents have been admitted since licensure.
Food Service : No residents have been admitted since licensure.
Incidental Medical Services : No residents have been admitted since licensure.

Exit interview and a copy of this report and appeal rights were provided to Shaunda Williams.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
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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