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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603584
Report Date: 05/05/2023
Date Signed: 05/08/2023 08:55:56 AM

Document Has Been Signed on 05/08/2023 08:55 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:LOS ROBLES GUEST HOMEFACILITY NUMBER:
198603584
ADMINISTRATOR:AVILA, LEAHFACILITY TYPE:
735
ADDRESS:1657 N LOS ROBLESTELEPHONE:
(626) 797-0808
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 12CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Leah AvilaTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an announced subsequent Pre-Licensing visit stemming from initial Pre-Licensing visit dated 03/27/23. LPA wad met by Administrator Leah Avila and explained the purpose of the visit.

LPA conducted tour to address corrections required to meet Title 22 regulations. Binet lockLPA observed the following corrections:

· Cabinet lock in kitchen containing knives and sharps was replaced. Per Administrator Avila, knives and sharps have been relocated to near by kitchen closet and have been placed in a lock box. LPA observed closet to be locked and inaccessible to 6 out of 6 clients in care.

· Cabinet lock containing disinfectants/cleaning solutions was replaced and LPA observed these chemicals to be inaccessible to 6 out of 6 clients in care.

· Water temperature reading was measured at 109.6 degrees F.

· Light fixture in bedroom#1 bathroom was replaced.

Per California Code of Regulations Title 22, the home meets the minimum physical plant requirements.



Exit interview held and a copy of the report was provided via email due to printer problems.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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