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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603732
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:58:22 PM

Document Has Been Signed on 10/15/2024 02:58 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:HOLIDAY HOUSEFACILITY NUMBER:
198603732
ADMINISTRATOR/
DIRECTOR:		MONTES, RICARDOFACILITY TYPE:
735
ADDRESS:11854 HEMLOCK ST.TELEPHONE:
(626) 443-1313
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 3CENSUS: 3DATE:
10/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator Ricardo MontesTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Ricardo Montes and explained the reason for the visit.
The purpose of the visit is to conduct a pre-licensing visit.
The visit included the following domains:
Infection Control, Physical, Plant/ Environmental Safety, Operational Requirements, Personnel Records- Staff Training, Client records- incident Reports, Client rights/ information, Food Service, Health Related Services, and Disaster Preparedness.
The facility is in a residential area and is a one-story family home. There are three (3) client bedrooms, two (2) bathrooms, living room, dining area, kitchen, front yard, and back yard. LPA conducted the tour with Administrator Ricardo Montes and observed the following:

Smoke detectors/carbon monoxide detectors were observed in common areas and in each client’s bedroom. Client’s bedrooms were observed to have required furniture such as bed frames, dressers, chairs, lamps, and sufficient closet space. The required bedding was also observed. The home has two (2) bathrooms and were clean and sanitary. The water temperate was tested and measured within the required 105-120 degrees. There is a fire extinguisher in dining room. All appliances in kitchen were observed to be clean and operational. Sufficient 2 days of perishables and 7-day supply on non-perishables food was observed. Cleaning supplies, chemicals and sharp knives are stored in a locked cabinet in laundry room. Medications are locked in a cabinet in hallway. The backyard has a shaded area with patio furniture. The home does not have a pool or any large bodies of water. There are no cameras inside the home.

Component 3 completed at today's visit.

"Pre-Licensing is complete and this facility has no deficiencies



Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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