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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608378
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:26:45 PM

Document Has Been Signed on 04/05/2022 02:26 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:FOUR DIAMONDSFACILITY NUMBER:
197608378
ADMINISTRATOR:HELEN TORRESFACILITY TYPE:
740
ADDRESS:1926 TILLIE COURTTELEPHONE:
(626) 581-1695
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 3DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Licensee; Helen TorresTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Assistant House Manager Samson Deles and explained the reason for the visit. Licensee/Administrator Helen Torres, House Manager Daniel Hurtado, and RN Shanelle Hurtado arrived shortly thereafter. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Administrator toured the home and inspected (3) resident bedrooms, (1) staff room, (2) bathrooms, living room, dining room, kitchen, and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 in the hallway and measured at 109.7F which is within the required 105F - 120F degrees. Grab bars are available for each toilet and showers are equipped with non-skid mats. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector located in the hallway. There is a fire extinguisher located in the dining room which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and disinfectants are locked in the garage and are inaccessible to residents. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff were observed wearing masks and screening visitors at entry.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (3) out of the (3) resident medications were reviewed. Medications are centrally stored in a cabinet located in the kitchen. Medications are documented properly and given as prescribed.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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