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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603870
Report Date: 02/06/2025
Date Signed: 02/06/2025 01:24:06 PM

Document Has Been Signed on 02/06/2025 01:24 PM - 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:PASA ALTA EASTFACILITY NUMBER:
198603870
ADMINISTRATOR/
DIRECTOR:		BROWN, DEWALTFACILITY TYPE:
735
ADDRESS:1722 S AVINGTON AVENUETELEPHONE:
(626) 926-3519
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 0DATE:
02/06/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Dewalt Brown, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Galarza made an Announced visit and met with Licensee Dewalt Brown and Administrative Assistant Brandon Brown to conduct a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) on 1/13/2025 for an initial application of an Adult Residential Facility (ARF) to serve developmentally disabled adults ages 18-59. The home will be a level 4i Adult Residential Facility (ARF) vendored by San Gabriel/Pomona Regional Center. The total requested capacity is for six (6) ambulatory residents.

Structure: Facility is a single-story home located in a residential area consisting of four (4) bedrooms [2 private and 2 shared], three (3) bathrooms, kitchen, dining room, living room, laundry room in the garage, 2 car attached garage, and backyard patio area. Front yard is landscaped with grass. Bedrooms: Two (2) bedrooms are designated as private bedroom and two (2) will be shared. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lighting. Bathrooms: Three (3) full bathrooms are equipped with working toilets, wash basins, bathtub/ walk-in shower. 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 closet. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. _____ Three (3) fully charged fire extinguishers are in place. 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/Carbon Monoxide: There are battery operated dual carbon monoxide/smoke 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: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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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: PASA ALTA EAST
FACILITY NUMBER: 198603870
VISIT DATE: 02/06/2025
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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 is pending approval. It is scheduled for Feb.13, 2025. Component III: Component III was waived. 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 Dewalt Brown. A copy of the report will be emailed due to printing issues. 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: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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