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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602212
Report Date: 01/26/2022
Date Signed: 01/26/2022 02:59:02 PM

Document Has Been Signed on 01/26/2022 02:59 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:BUNGALOWFACILITY NUMBER:
198602212
ADMINISTRATOR:RAMIREZ, CARINAFACILITY TYPE:
740
ADDRESS:1314 WOODBURY ROADTELEPHONE:
(626) 296-6977
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Linda Morales, Administrator TIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with House Manager Stacy Lopez and explained the purpose of the visit. Administrator Linda Morales arrived shortly after. There are 6 residents 60 and older of which 3 are ambulatory and 3 non ambulatory. Facility is a single story home located in a residential area consisting of 5 client rooms, 3 bathrooms, living room, dining room, backyard patio area, and detached garage. The last fire drill was completed on December 10, 2021. Administrator certificate expires January 03, 2023.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has ability to designate isolation room.
· Five (5) client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were equipped with alcohol-based hand sanitizer.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
·
No deficiencies cited.
·
Exit interview was conducted with Administrator Linda Morales.. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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