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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603707
Report Date: 02/23/2024
Date Signed: 02/23/2024 01:36:22 PM

Document Has Been Signed on 02/23/2024 01:36 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMALIA HOME - OLYMPICFACILITY NUMBER:
198603707
ADMINISTRATOR:SANVICTORES, JOURDANFACILITY TYPE:
735
ADDRESS:8526 OLYMPIC BLVD.TELEPHONE:
(562) 805-5615
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 4CENSUS: 0DATE:
02/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Jourdan Sanvictores- LicenseeTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Sanjay Vaid and Luis Mora made an announced visit and met with Administrator Jourdan Sanvictores to conduct an announced Pre-Licensing evaluation.
An initial application was submitted to Community Care Licensing Department (CCLD) for an Adult Residential Facility (ARF) to serve adults between the ages of 18 - 59. The requested capacity is four (4) which consist of three (3) ambulatory and one (1) non-ambulatory clients. Structure: Facility is a single-story home located in a residential area consisting of two (2) client private bedrooms, one (1) master bedroom will have two clients sharing, two (2) bathrooms, kitchen, dining room, living room, laundry area. Backyard has a covered shaded area and is currently furnished. Front yard is landscaped with grass and back yard is landscaped with cement and grass. Bedrooms: Client bedrooms are equipped with one bed, nightstand, lamp, and overhead lighting. Master bedroom has two beds, two lamps, two nightstands, two chairs and overhead lighting. Bathrooms: Two (2) full bathroom equipped with working toilets, wash basins, bathtub/ walk-in shower. Water Temperature: Water temperature in the bathrooms and kitchen was tested and measured between 105 -120 degrees Fahrenheit as required. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in hallway closet. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. One (1) fully charged fire extinguisher was observed. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Emergency water supply was observed. Smoke Detectors: There are electrical smoke/carbon monoxide detectors located in all bedrooms, common areas, and hallways, alarms/detectors are hardwired. Appliances: Refrigerator, oven, microwave, dishwasher, and washer/dryer are in new condition. The residence is equipped with air-conditioner and heating units located in each bedroom, living room and staff areas. Toxins: Cleaning supplies, and toxins are locked only accessible to staff.
No outstanding or pending items were observed by the LPAs requiring additional pre-licensing visits. LPAs will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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