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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603770
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:44:28 AM

Document Has Been Signed on 07/11/2024 11:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALLY CARE GROUP @ HIGHLANDFACILITY NUMBER:
198603770
ADMINISTRATOR/
DIRECTOR:
ALADE, ADENIYIFACILITY TYPE:
735
ADDRESS:761 HIGHLAND PLTELEPHONE:
(951) 261-1221
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 0DATE:
07/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Adeniyi Alade - Administrator TIME VISIT/
INSPECTION COMPLETED:
12:01 PM
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Licensing Program Analysts (LPA) Erik Zaragoza conducted an announced Pre-Licensing visit and met with Adeniyi Alade, Administrator for the facility, and was granted entrance. This Pre-Licensing inspection is bring conducted as an initial application to be licensed.

The facility has an approved fire clearance to serve six (6) total ambulatory clients. The facility is a single-story home located in a residential neighborhood in the city of San Dimas. The facility consists of a dining room, two (2) living rooms, an activity room, a kitchen, six (6) client bedrooms, a laundry room, and two (2) client bathrooms which had a hot water temperature reading of 111.7 Degrees Fahrenheit and 112.3 degrees Fahrenheit respectively, as well as a back yard with shaded area and a detached garage.

The following was inspected during the evaluation with the Administrator and determined to be compliant with Title 22 Regulations. A locked storage area for central storage of medications was observed in the activity room of the facility. Cleaning supplies are kept separate from food supplies and are stored in the locked supply closet which is located in the laundry room of the facility. The walls, ceilings, floors, window screens and areas around the facility were clean and in good repair. Three (3) fire extinguishers were located throughout the facility. The carbon monoxide and smoke detector was observed to be operational. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back areas of the facility were observed to be clean and free of debris.

No pools or bodies of water were observed in or around the facility. An operating telephone was observed on the premises, which is easily accessible and available for resident use. The refrigerator was observed to be operable at 41 degrees and freezer below 0 degrees. The first-aid kit was reviewed and is kept locked in a main hallway of the facility.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALLY CARE GROUP @ HIGHLAND
FACILITY NUMBER: 198603770
VISIT DATE: 07/11/2024
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Food storage and preparation areas, which include pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Food utensils, dishes, and glasses were clean and sufficient for the number of clients to be served.

Hot water temperature was tested and fell within the required range of 105 F – 120 F. The backyard activity area was observed to have a well shaded area and was furnished for outdoor use.

The Component III Orientation was held during today’s visit. No outstanding or pending items were observed by LPA requiring additional follow up visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed Pre-Licensing facility evaluation visit conducted.

Exit Interview conducted and a copy of the report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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