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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603615
Report Date: 06/13/2023
Date Signed: 06/13/2023 04:44:04 PM

Document Has Been Signed on 06/13/2023 04:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WORKMAN LANEFACILITY NUMBER:
198603615
ADMINISTRATOR:SMITH, JASON K.FACILITY TYPE:
735
ADDRESS:647 E. WORKMAN LANETELEPHONE:
(626) 714-3100
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 4CENSUS: 0DATE:
06/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jason Smith TIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Christine Wong, conducted an announced visit to the facility for purpose of a Pre-licensing evaluation. LPA met with Initial Administrator Jason Smith and Potential Administrator Melissa Allen-Zhang who assisted with today's visit.

An application was submitted to CCLD on 09/16/2022, for initial license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18 to 59 years, The requested capacity is for 3 non-ambulatory and 1 ambulatory.

During today's visit, LPA Wong utilized the Compliance and Regulatory Enforcement (CARE) tools for the pre-licensing visit today :

1. Physical Environmental and Safety: The facility is a single story house and is located in a residential neighborhood area. The facility includes living room, dining area, kitchen, four clients bedrooms, three bathrooms and an attached garage. The passageways, walkways, driveways, steps and patios are free from obstructions. All client bedrooms have one bed, one chair, night stand, drawer and sufficient closet space and lighting. Bedroom#2, #3 and #4 are for non-ambulatory clients. All bathrooms have a working toilet, wash basin and bath tub/shower. Bathroom#2 will accommodate non-ambulatory clients in a wheel chair. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in client's own closet. The smoke detectors and carbon monoxide detectors are inter connected and they are all operational. Stove burners, oven, microwave, washer, and dryer are all working probably. The facility is equipped with central air and heat. All the cleaning supplies and chemicals are locked in the storage room next to the living room. The hot water temperature in 3 bathrooms were tested between 116.9 degrees F and 118.4 degrees F which is within the Title 22 Regulation. There's no pool/jacuzzi or pets in the facility. The facility has a land line telephone system on the premises.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WORKMAN LANE
FACILITY NUMBER: 198603615
VISIT DATE: 06/13/2023
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2. Operational Requirements: The facility fire Clearance was approved on 06/08/2023 with 3 non-ambulatory and 1 ambulatory, bedroom#1 is ambulatory and bedroom#2, #3 and #4 are non-ambulatory. The weekly food menu post on the refrigerator door. The facility has a shaded area with tables and chairs for client to utilize for outdoor activity. The facility will be handling cash resources of clients and has a surety bond for $1000. All the recreational supplies are stored in living room cabinet and garage.

3. Personnel Training: All staff files will be stored and locked in the file cabinet outside from the kitchen.

4. Clients Records-Incident Reports: All the clients' files will be stored and locked in the file cabinet outside from the kitchen

5. Client's Right- Information: The facility will ensure each client has their personal right to be accorded safe, healthful and comfortable accommodations.

6. Food Service: The facility refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. Dishes, cups and flat ware are stored in the kitchen cabinet inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored and locked in the file cabinet outside from the kitchen.

7. Health Related Services: The medication will be centrally stored and locked in the facility file cabinet outside from the kitchen. A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in staff office cabinet and available for staff use but inaccessible to clients.

8. Disaster Preparedness: The facility has an updated emergency disaster plan dated on 2/1/23 posted on the wall next to the file cabinet outside from the kitchen area and has at least two alternative location.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Centralized 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: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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