198603557-1-31-2023-28-AS-AREA-CNLPK9-20230131102242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603557
Report Date: 01/30/2023
Date Signed: 01/31/2023 10:23:11 AM

Document Has Been Signed on 01/31/2023 10:23 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:	PEOPLE'S CARE NOGAL		FACILITY NUMBER:	198603557
ADMINISTRATOR:	TIGHE, JOSEPH		FACILITY TYPE:	737
ADDRESS:	8716 NOGAL AVENUE		TELEPHONE:	(909) 287-3557
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90606
CAPACITY: 4		CENSUS: 0	DATE:	01/30/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joseph Tighe		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Angelica Rea conducted an announced visit to the facility for purpose of a Pre-licensing evaluation. Also present at today's visit was Cristin Nicoletti, Project Manager, Jose Mendoza, Regional Director, Jasmin Smith, Assistant Administrator, and Martin Mercado, District Manager. An application was submitted to CCLD on 01/19/2022, for Initial license for a Adult Residential Facility to serve age range 18 through 59. The requested capacity is for 4 non-ambulatory. Structure: The facility is a single story house and located in a residential neighborhood area. Facility is a 4 bedrooms, 3 bathrooms, kitchen, living room, staff office, dining area and Activity Room. The client bedrooms are spacious and will easily accommodate the client's furnishings. The yard has a covered, shaded area for table and chairs. The passageways, walkways, driveway are free from obstructions. The front, back and side areas are free of hazards and maintained in a good condition. Signal system: The facility has a delayed egress with key and code to enter into the facility and LPA observed and its operational Bedrooms Residents: There is one bed in each client's bedroom. Each bedroom has one beds, one chairs, one night stand, one dresser, one closet and overhead lighting. Bathrooms: All bathrooms have a working toilet, wash basin and shower.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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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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: PEOPLE'S CARE NOGAL	FACILITY NUMBER: 198603557
	VISIT DATE: 01/30/2023

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in client's closet and the personal hygiene supplies will be stored and locked in the file cabinet in the living room.

Emergency Phone Numbers, Exit Plan & Menu:
The facility has a landline phone # and the phone number is 562-550-3312.
Tested & readily available for use in staff office. Fire Extinguisher located in the kitchen mounted on wall

Food Service:
Dishes, cups and flat ware are stored in the kitchen cabinets, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored and locked in a kitchen cabinet. Food supply adequate stored in the kitchen and consists of the following: 2 days perishable and 7 days non-perishable.

Smoke Detectors
The smoke detector/carbon monoxide detector(s) were tested & are inter-connected. There are additional Carbon monoxide detectors located in hallway and living room area and are operational.

Appliances:
Stove burners, oven, microwave, washer, and dryer working properly. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The client's bedroom is equipped with central air and heat.

Toxins:
All cleaning supplies and toxins are locked and stored under the sink and in the laundry room.

Water Temperature:
The hot water temperature in bathroom and kitchen was tested and measured between 105 and 120 degree degrees Fahrenheit as required.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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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: PEOPLE'S CARE NOGAL	FACILITY NUMBER: 198603557
	VISIT DATE: 01/30/2023

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Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored and locked in a kitchen cabinet, available for staff use but inaccessible to clients. Clients' medication is centrally stored and locked in the cabinet in the laundry room.

Clients & Staff Files:
Applicant will be handling client cash resources, cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked file cabinet in the staff room. The client and staff files are stored and locked in the file cabinet in the staff room.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use and they are located in the living room, and in the activity room.

Activity Room
There is a separate activity room for client use. There is a television, activity supplies, and an extra refrigerator.

Component III:
It was Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. 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: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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