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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603789
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:59:13 AM

Document Has Been Signed on 01/09/2025 11:59 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:JADE PROMISED HOMEFACILITY NUMBER:
198603789
ADMINISTRATOR/
DIRECTOR:		PEREYRA, RHODERICKFACILITY TYPE:
735
ADDRESS:15753 FELLOWSHIP STTELEPHONE:
(626) 374-9450
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 0DATE:
01/09/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Applicant Rhoderick PereyraTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an announced prelicensing visit with applicant Rhoderick Pereyra. Licensing received an initial license application for an Adult Residential Facility to serve up to (4) ambulatory clients on 6/10/24. Fire clearance was approved on 10/15/24.

The facility is a single story home with (4) bedrooms and (2) bathrooms. There is a front and back yard. Facility has an attached garage and detached shed for storage. LPA completed the visit using the following inspection tool domains:

Infection Control: Infection Control Plan was reviewed by LPA. Plan follows title 22 regulations
Physical Plant and Environmental Safety: Physical plant is in clean and good condition. Water temperature measured within regulation. Fire and CO2 detectors were tested and operational. Sharps and toxins are in locked areas. Required furniture was observed throughout the home.
Operational Requirements: Fire clearance approval was observed. Plan of operation was observed. Outdoor activity space and supplies for clients was observed.
Personal Records - Training: Locked storage space for staff files was observed. Mock files observed.
Client Records - Incident Reports: Locked Storage space for client files observed. Mock Files in place
Client Rights - Information: Requires posting observed regarding personal rights.
Food Service: 2 day perishable and 7 day non perishable supply was observed.
Health Related Services: First Aid Kit was observed
Disaster Preparedness: Facility has emergency disaster plan in place.

Component III was also completed at the time of this visit. The Physical Plant is cleared.

An exit interview was conducted, and a copy of this report has been furnished to Applicant Rhoderick Pereyra, 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: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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