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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603814
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:49:57 AM

Document Has Been Signed on 12/12/2024 11:49 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:NORTH HOMEFACILITY NUMBER:
198603814
ADMINISTRATOR/
DIRECTOR:		ROJAS, DIANAFACILITY TYPE:
735
ADDRESS:1306 N HUNTINGTON BLVDTELEPHONE:
(909) 671-2812
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 0DATE:
12/12/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Diana Rojas, applicant/administratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Cynthia Chan, Mayra Cota, and Luis DeLeon conducted an announced prelicensing inspection on 12/12/24. LPAs met with applicant/administrator, Diana Rojas.
The fire clearance has been approved for a capacity of 4 ambulatory only adults, ages 18 through 59. There are currently no individuals residing at the facility.

LPA inspected the facility using the Pre-licensing Inspection tool and observed the following. Component III was also completed during the visit today.

Structure: Facility is a one-story home consisting of 4 client bedrooms, 2.5 bathrooms, living room, dining room, kitchen, nook, laundry room, and detached garage. There are no pools or bodies of water on the premises. There is a shaded outdoor patio in the rear for clients to use.

Bedrooms: There are 4 private bedrooms and furnishing equipped for each client such as a bed, nightstand, adequate closet space, a chair, and lighting.

Bathrooms: There are a total of 2.5 bathrooms. There are 2 communal bathrooms and a half bath in bedroom #3.

Surveillance: The facility uses surveillance monitors in the common areas, living room, dining room, and kitchen.



Staff and Client files: Staff and Client files will be maintained at the facility. Staff files will be locked in the nook area.

Linens & Hygiene supplies: Extra supplies of linens and hygiene are observed in storage cabinets. There are sufficient amount of linens available to permit weekly changing.

Appliances: There is a stove, oven, washer and dryer. The stove burners were not operable at this time.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NORTH HOME
FACILITY NUMBER: 198603814
VISIT DATE: 12/12/2024
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Toxins: All cleaning products will be stored and locked in the garage.

Emergency phone numbers, Exit Plan, and Menu: The emergency phone numbers and exit plan are posted. The daily menu is posted in the kitchen. Facility landline is (909) 622-6133.



Food service: Adequate supplies of non-perishable items are observed. The perishables will be purchased once they obtain clients in the home. The refrigerator is maintained at 37 degrees F and freezer at 0 degrees F. There are sufficient cups, plates, and utensils stored in the kitchen cabinets. Knives will be locked.

Smoke Detectors and Fire alarm: The facility has smoke and carbon monoxide combo detectors located in each of the client rooms, hallways, and common areas. The facility will conduct disaster drills at least every quarter. There is a fire extinguisher mounted on the wall.

Medications: Medications will be centrally stored and locked. The first aid kit contains all the required supplies along with the current first aid manual.

The following discrepancies were observed and must be corrected.
* The hot water temperature is not within the required range of 105-120 degrees F.
* Stove burner is not operating.

The proof of correction shall be submitted to LPA by 12/19/24.
An exit interview was conducted. A copy of this report was given to the applicant.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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