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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603739
Report Date: 08/02/2024
Date Signed: 08/02/2024 11:25:52 AM

Document Has Been Signed on 08/02/2024 11:25 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:JC LOVING HOMEFACILITY NUMBER:
198603739
ADMINISTRATOR/
DIRECTOR:		CABRERA, JEANETHFACILITY TYPE:
735
ADDRESS:616 SYCAMORE DR.TELEPHONE:
(909) 253-9498
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 2CENSUS: 0DATE:
08/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jeaneth Cabrera, Administrator TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Galarza made an Announced visit and met with Licensee Jeaneth Cabrera to conduct a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) for an initial application of an Adult Residential Facility (ARF) to serve developmentally disabled adults ages 18-59. The home will be vendorized by Eastern Los Angeles Regional Center as a level 4i Adult Residential Facility (ARF). The total requested capacity is for two (2) ambulatory residents.

Structure: The facility is a single story home located in a residential neighborhood. It consists of three (3) bedrooms [2 resident bedroom & 1 live-in staff], living room, dining room, laundry room, kitchen, detached garage, and backyard with covered patio area. Bedrooms: All bedrooms are private and meet HCBS federal requirement #7 "privacy in his/her sleeping or living unit. Room doors had locks. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lightning. Bathrooms: Have a working toilet, wash basin, and bathtub. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens are stored in facility closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. One (1) fully charged fire extinguishers is in the home. Facility has an operable 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. Smoke Detectors: There are electrical & inter-connected dual smoke/carbon monoxide detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in good condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff.

***Narrative continues next page. ****

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: JC LOVING HOME
FACILITY NUMBER: 198603739
VISIT DATE: 08/02/2024
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Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: The facility has a designated file area. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 2/15/24 for a total capacity of 2 ambulatory residents.Component III: Component III was completed. An Infection Control Plan and Emergency Disaster Plan for Adult Community Care Facilities and Residential Care Facilities was submitted.

No items of correction were observed.

An exit interview was conducted with Licensee. A copy of the report was issued. 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, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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