198603733-6-20-2024-28-AS-BTAO-D6EPYB-20240620114339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603733
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:43:52 AM

Document Has Been Signed on 06/20/2024 11:43 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:	GRACE PINEDA'S HOME INC		FACILITY NUMBER:	198603733
ADMINISTRATOR/ DIRECTOR:	ULLOA, SILVIA		FACILITY TYPE:	735
ADDRESS:	347 EAST GREENHAVEN ST		TELEPHONE:	(626) 967-2961
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY: 4		CENSUS: 2	DATE:	06/20/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:02 AM
MET WITH:	Silvia Ulloa, applicant		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tao conducted an announced pre-licensing inspection. LPA met with Silvia Ulloa, applicant/ administrator. Applicant is applying for Adult Residential Facility to serve clients for age range from 18 years old through 59 years old. The requested capacity is four (4), ambulatory only. Currently, there are two (2) clients residing at the facility and are at the day program or school at the time of visit. Facility receives case management services provided by San Gabriel Pomona Regional Center. This is a change of facility type. The facility is currently licensed as Grace Pineda Small Family Home, facility # 197806849. It is a small family home to serve children. Fire clearance: Fire clearance is granted for four (4) ambulatory clients on 05/03/24. Structure: The property is a single-family residence located in a residential neighborhood and consist of three (3) client bedrooms, one (1) client bathroom, one (1) staff bedroom, two (2) staff bathrooms, living room, kitchen, dining room, office, and laundry area in the attached garage. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Garage is not accessible to clients. Facility had no pool or bodily of water. (- continued on LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE PINEDA'S HOME INC	FACILITY NUMBER: 198603733
	VISIT DATE: 06/20/2024

NARRATIVE

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Bedrooms and Bathrooms for Clients:
Bedrooms are spacious, accommodated for clients and in compliance with regulation. Bathrooms have grab bars maintained for each toilet, bathtub and shower.

Linens & Hygiene Supplies:
Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash clothes and towels are observed.

Food Service:
Facility had the required food wares stored in the kitchen cupboards and kitchen appliances in place which were inspected and in good repair. Food supply consist of two days of perishable and two weeks of non-perishable was observed.

Smoke Detectors:
Smoke /carbon monoxide detectors are tested and operable which are located in hallways and each bedroom.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to clients. They are stored separately from food source.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan and Labor law poster are posted. Exit Plan are available for review.
(-continued on LIC 809 C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE PINEDA'S HOME INC	FACILITY NUMBER: 198603733
	VISIT DATE: 06/20/2024

NARRATIVE

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Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided.

Clients & Staff Files:
Locked cabinets for records of staff and clients are installed and available. Clients file are observed. Applicant will handle cash resources for clients. Administrator certificate is current with expiration date on 6/15/25.

Water Temperature/ Fire extinguishers:
Water was measured at 110.6 degrees Fahrenheit which was in compliance with Reg Title 22. Fire extinguisher was fully charged which was mounted on the kitchen wall. The last service was on 3/27/24.

Menu and phone:
Menus are available for review. Free landline telephone is available for clients’ use and operable.

Findings/ Exit:
No issue was observed during today’s visit. Exit conference was conducted. LPA conducted Component III orientation to applicant during the pre-licensing visit.

A copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

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