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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603872
Report Date: 02/14/2025
Date Signed: 02/14/2025 10:19:58 AM

Document Has Been Signed on 02/14/2025 10:19 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:SHALIS CARE CENTERFACILITY NUMBER:
198603872
ADMINISTRATOR/
DIRECTOR:		WALTERS, ALICIAFACILITY TYPE:
735
ADDRESS:1545 MURAL DRTELEPHONE:
(626) 241-7876
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
02/14/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:House Manager- Melvin Alvarez-MendozaTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Kimberly Ramirez made an announced visit and met with House Manager Melvin Alvarez-Mendoza and Licensee Sean Walters, to conduct a Pre-Licensing evaluation.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of a Adult Residential Facility (ARF) to serve developmentally disabled adults ages 18 - 59 with. Structure: Facility is a single-story home located in a residential area consisting of four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, family room, garage, and a backyard with seating and shade. Operational Requirements: The facility provided proof of liability insurance during today's visit. Auditory devices are in working condition. Bedroom Clients: Bedrooms are equipped with a bed, night stand, chair, lamp, dresser, trash bins, and overhead lighting. Bathrooms: One (1) full bath equipped with working toilet, wash basins, bathtub/shower and One (1) full bath equipped with working toilet, wash basins, 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 is stored in linen closets. Emergency Phone Numbers, Exit Plan: Emergency numbers and Exit plans are posted and readily available for review. Three (3) fully charged fire extinguishers was observed. Facility has a 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. Emergency water supply was observed.

See 809-C
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SHALIS CARE CENTER
FACILITY NUMBER: 198603872
VISIT DATE: 02/14/2025
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Carbon Monoxide/Smoke Detectors: Where observed and tested. 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. Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit and not more than 120 degrees Fahrenheit. 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. Resident & Staff Files: Designated area for files will be in locked closet and digital. Pools/Jacuzzi/Body of Water: No bodies of water were observed. Fire Clearance: Fire clearance is still pending as of 2/14/25. Component III: Component III was reviewed during inspection.

Pre-Licensing is complete, and this facility has no deficiencies. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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