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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800633
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:13:44 PM

Document Has Been Signed on 10/21/2022 04:13 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:JOMAR RESIDENTIAL CARE CENTERFACILITY NUMBER:
197800633
ADMINISTRATOR:JOSEPHINE SAPALARANFACILITY TYPE:
735
ADDRESS:3920 N FRIJO AVETELEPHONE:
(626) 338-4551
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: 4DATE:
10/21/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Omar Sapalaran, administrator assistantTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tao conducted an announced Case Management for Change of capacity visit. Licensee applied for the change the capacity from six (6) to four (4) clients, in which to serve four (4) developmentally disabled non-ambulatory clients, ages 18-59. The facility is a vendor of San Gabriel/ Pomona Regional Center. LPA explained the purpose of today's visit to Omar Sapalaran, Administrator assistant, who assisted with this visit.

The facility’s plan of operation and physical plant sketch were provided to Licensing. Fire inspection was conducted and fire clearance was approved for four (4) non-ambulatory clients on 10/06/22. San Gabriel/ Pomona Regional Center had approved the change of capacity from six to four clients on 06/06/2021 which supported the change of capacity of the facility.

During today's visit LPA toured the facility. LPA inspected the facility per the updated physical plant sketch and granted fire clearance. Facility’s smoke detector and carbon monoxide detectors were tested and operable. Hot water was measured at 113.8 degree Fahrenheit which was within Title 22 Regulation guidelines. Sufficient supply of perishable and nonperishable foods was observed. Medication was centrally stored in a locked cabinet in the kitchen and inaccessible to clients. Client records were stored in a locked cabinet and inaccessible to clients. Toxic substances are inaccessible to clients.

No deficiencies were observed regarding the application for the change of capacity during this visit. Exit interview was held and a copy of the report was provided to Omar, administrator assistant.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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