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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603609
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:49:41 AM

Document Has Been Signed on 01/09/2024 11:49 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: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:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Helen Navarro - Admin TraineeTIME COMPLETED:
12:03 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Helen Navarro (Admin Trainee) and explained the reason for the visit. The facility is licensed to serve 4 ambulatory clients, of which 1 may be non-ambulatory in the age range of 18 through 59. Facility is operating within the scope of its license.

A tour of the single-story facility included the 3 client bedrooms, 2 bathrooms, living room, dining area, kitchen, laundry area, recreation room, front yard, backyard and attached garage. LPA Mora conducted the tour with Helen and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and garage refrigerator. Sharps were observed locked in a kitchen cabinet and cleaning chemicals were observed locked under the kitchen sink. The First Aid kit is kept in the laundry area and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinets. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a kitchen cabinet. Client and staff files are kept locked in a hallway cabinet. All bedrooms have all required furniture, lighting, and bedding. The bathrooms were observed with shower mats and required grab bars for non-ambulatory clients. The water temperature was tested in the both bathrooms and measured at 106.2 degrees F and 105.4 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the laundry room and it is fully charged. Smoke detectors combined with carbon monoxide were observed throughout the facility and in each room and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for 4 clients and 5 staff. LPA interviewed 1 staff and could not interview clients due to being at the Adult Day Program (ADP) during the visit. LPA observed the administrator certificate for Wanda Magee - 6016881735 that expires on 06/01/24.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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