198603590-9-11-2023-28-AS-BTAO-CVKW3W-20230911165639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603590
Report Date: 09/11/2023
Date Signed: 09/11/2023 04:56:43 PM

Document Has Been Signed on 09/11/2023 04:56 PM - 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:	ALL FOR MOMS HOMECARE		FACILITY NUMBER:	198603590
ADMINISTRATOR:	TRUONG, PHUOC		FACILITY TYPE:	740
ADDRESS:	16136 E CLOVERMEAD ST.		TELEPHONE:	(626) 456-1066
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	6	CENSUS: 6	DATE:	09/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Phuoc Truong (Henry), applicant/administrator		TIME COMPLETED:	04:30 PM

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 Analysts (LPA) Tao conducted an unannounced visit to the facility for purpose of an annual inspection. LPA met with Phuoc Truong, administrator, who assisted with the visit. The facility is licensed to serve Residential Care Elderly to serve elderly, ages 60 years old and older, and has dementia program. The capacity is six (6) including five (5) non-ambulatory and one (1) bedridden. The facility has approved of six (6) hospice waiver. Currently, five (5) residents are non-ambulatory and no bedridden residing at the facility. Annual licensing fees are current. Administrator certificate is current and the expiration date is 12/5/23. Two live-in staff are residing in bedroom #6. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and staff/residents were interviewed. LPA toured the facilities physical plant, indoor and outdoor. The facility is located in a residential neighborhood. Facility is a single house with six (6) resident bedrooms, two (2) bathrooms, living room, kitchen, backyard with shaded area, and laundry room. Passageways, walkways, driveways, steps and patios are free from obstructions. Residents' bedrooms and bathrooms are spacious and will easily accommodate the residents furnishings. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 113.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Last fire drill was conducted on 7/10/23. (-continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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: ALL FOR MOMS HOMECARE	FACILITY NUMBER: 198603590
	VISIT DATE: 09/11/2023

NARRATIVE

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Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers’ last service is 8/21/123 and are fully charged.

Due to insufficient time, this annual visit needs a further inspection for staff/residents file reviews, medication reviews and complete the other domains in CARE tools.

An Exit interview was completed with Administrator. A copy of this licensing report LIC 809 was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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