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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603609
Report Date: 12/19/2022
Date Signed: 12/19/2022 11:34:24 AM

Document Has Been Signed on 12/19/2022 11:34 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:HALIFAX HOUSEFACILITY NUMBER:
198603609
ADMINISTRATOR:MAGEE, WANDAFACILITY TYPE:
735
ADDRESS:4539 HALIFAX RD.TELEPHONE:
(626) 443-1313
CITY:EL MONTESTATE: CAZIP CODE:
91731
CAPACITY: 4CENSUS: 4DATE:
12/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mary Watson Assistant Executive DirectorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Wanda Magee and Mary Watson Assistant Executive Director.
The purpose of the visit is to conduct the pre licensing visit.
Tour of the facility was conducted and the following was observed:
Facility contains 3 Client Bedrooms and 2 Client Bathrooms, dining room, living room, TV room, and activity room.
Locked storage area for central storage of medications is available.
Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair.
Locked storage area for poisons, toxic, cleaning solutions, disinfectants, etc.
Doors, stairways, and passageways are unobstructed.
An emergency exiting plan and emergency phone numbers posted in an appropriate place.
An operating telephone on the premises and available to clients.
First aid supplies, which include sterile first aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first aid manual is maintained.
Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly.
Furniture is room/client appropriate, clean and in good repair.
Beds have required linen/supplies: pillow case, mattress pads, fitted sheet, flat and blanket and bedspreads.
A sufficient supply of linens to permit weekly changing or more often to insure clean linen at all times for clients. Equipment and supplies for client personal hygiene is available and on site.
Garbage cans have tight fitting covers.
Emergency lighting is maintained.
"Pre-Licensing is complete and this facility has no deficiencies."
Component 3 completed at today's visit.
Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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