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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603570
Report Date: 02/13/2024
Date Signed: 02/13/2024 10:51:08 AM

Document Has Been Signed on 02/13/2024 10:51 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PEOPLE'S CARE MCGEEFACILITY NUMBER:
198603570
ADMINISTRATOR:THOMAS, JASMINEFACILITY TYPE:
737
ADDRESS:12545 MCGEE DRIVETELEPHONE:
(909) 287-3557
CITY:WHITTIERSTATE: CAZIP CODE:
90606
CAPACITY: 4CENSUS: 0DATE:
02/13/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jasmine Thomas- AdministratorTIME COMPLETED:
09:01 AM
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Licensing Program Analysts (LPAs) Sanjay Vaid and Angelica Rea made an announced visit and met with Administrator Jasmine Thomas to conduct a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of a Adult Residential Facility- Enhanced Behavioral Supports Home (ARF- EBSH). The requested capacity is for four (4) non-ambulatory. Structure: Facility is a single-story home located in a residential area consisting of four (4) private bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry area. The garage will be used for activities and extra storage. The backyard has an outdoor covered patio. Front and back yards are landscaped with grass. Bedroom Clients: Each bedroom is designated as a private bedroom. Bedrooms are equipped with one bed, nightstand, chair, lamp, and overhead lighting. Bathrooms: Two (2) full bathrooms equipped with working toilets, wash basins, bathtub/ walk-in shower with grab bars and anti-slip mats. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in bedroom closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. One(1) fully charged fire extinguisher was observed. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Emergency water supply was observed. Smoke Detectors/ Carbon-monoxide Detectors: There are electrical & inter-connected smoke detectors/carbon monoxide detectors located in all bedrooms, common areas, and hallways, tested and operational. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in new condition, and operational. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked under the sink and are only accessible to staff.
***Narrative continues next page.****
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PEOPLE'S CARE MCGEE
FACILITY NUMBER: 198603570
VISIT DATE: 02/13/2024
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Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within required range of 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual are kept in locked cabinet in laundry room. Clients & Staff Files: Designated area for client files will be in the kitchen in locked cabinet, and the staff files are located in staff office in locked cabinet, respectively. No health and safety concerns were observed. Fire Clearance: Fire clearance was approved on 08/04/2022 for 4 non-ambulatory, Component III: Component III was presented and reviewed with Administrator.

Physical plant is cleared at the time of visit.

An exit interview was conducted and a copy has been furnished to the applicant. Accordingly, LPA will submit a copy to the 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: Wei Siew Ho
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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