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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603780
Report Date: 10/24/2024
Date Signed: 10/24/2024 11:21:16 AM

Document Has Been Signed on 10/24/2024 11:21 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:CASA COLINA TRANSITIONAL LIVING CENTER-MELBOURNEFACILITY NUMBER:
198603780
ADMINISTRATOR/
DIRECTOR:		KAPLAN, STEPHANIEFACILITY TYPE:
735
ADDRESS:2873 MELBOURNE AVETELEPHONE:
(909) 596-7733
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 5CENSUS: 0DATE:
10/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Stephanie Kaplan, Rachel Trand and Linda LeyvaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Elizabeth Irra and Luis DeLeon conducted an announced pre-licensing visit. LPAs met with Stephanie Kaplan (Applicant), Rachel Tran (Director of Transitional Living Center) and Linda Leyva (Director of Accreditation). The facility is to serve (5) ambulatory individuals. Component III was also completed during this visit.

This is a single-story home that consists of: (3) bedroom, (2) bathrooms, living room, dining area, kitchen and detached garage.



The following was observed/inspected:
  • Physical plant is in good repair.
  • Building and grounds are free from hazards.
  • Smoke detectors tested and operable.
  • Carbon monoxide detector was tested and operable. Located in the hallway leading to the bedrooms.
  • Fire extinguisher (service date: 01/15/24) located in the kitchen.
  • Telephone (landline) operable. Per Applicant, facility has internet access.
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two-day supply of perishables and seven-day supply of non-perishable will be stocked upon the first admission.
  • Water supply observed (hallway closet).
  • The facility has dining table and sufficient chairs.
  • First Aid Kit inspected.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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: CASA COLINA TRANSITIONAL LIVING CENTER-MELBOURNE
FACILITY NUMBER: 198603780
VISIT DATE: 10/24/2024
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  • Clients have the appropriate furniture (one chair, night stand, adequate closet and drawer space).
  • Mattresses are in good repair.
  • There are enough bath towels, hand towels and wash cloths for all clients.
  • Hot water temperature measured the following: kitchen (109.0*), hallway bathroom (109.4) and bathroom inside room #1 (108.5*).
  • Refrigerator, stove, sinks, tubs, toilets and showers operate properly.
  • Facility has a washer and dryer that are fully operational located near the kitchen.
  • Client files will be stored inside the nursing station (building next door) and staff files are in the HR department and/or electronic.
  • Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly.
  • Outdoors: there is a shade area set up in the backyard to accommodate (5) clients.
  • Clients rights are posted.
  • Emergency Disaster Plan is posted.

No deficiencies observed. Exit interview conducted, copy of report provided to Stephanie Kaplan.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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