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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603021
Report Date: 01/24/2023
Date Signed: 01/24/2023 04:16:35 PM

Document Has Been Signed on 01/24/2023 04:16 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:FAMILY HOME LLCFACILITY NUMBER:
198603021
ADMINISTRATOR:VILLALVA, JOEL HFACILITY TYPE:
740
ADDRESS:1629 CALLE CIERVOTELEPHONE:
(626) 354-0265
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 5DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Joel Villalva- Licensee/AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Maldonado conducted an annual required visit. LPA met with Administrator, Joel Villalva and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files.

The facility cares for elderly residents with dementia and is allowed to care for two (2) hospice residents. LPA observed all resident bedrooms to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. (2) resident bathrooms were observed to have a shower, toilet, and wash basin. The showers accommodate non-ambulatory residents and have the required grab-bars and non-skid mats. The water temperature was tested and measured at 114*F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. Several fire extinguishers were observed throughout the facility. They had current inspections and were fully charged. All sharps were observed to be locked and inaccessible in a drawer in a kitchen drawer. Other cleaning supplies were locked and inaccessible, stored in a cabinet in bathroom# 2 and underneath the kitchen sink. All equipment was operational and in good repair. Additional linens were observed in the garage and in good repair. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit.

All resident files were reviewed and had updated emergency contact information and health screenings. (3) staff files were reviewed and had Criminal Background Clearances, health screenings, and proof of required annual training and certifications. All client medications were reviewed. They are documented properly and given as prescribed.


(Report continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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: FAMILY HOME LLC
FACILITY NUMBER: 198603021
VISIT DATE: 01/24/2023
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LPA observed Personal Protective Equipment (PPE) supplies was observed at the entrance of the facility- the central entry point for screening clients, staff, and visitors and in the hallway. PPE siganage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. All hand washing stations are fully stocked with liquid soap and paper towels.

Per California Code of Regulations, Title 22, and Health and Safety Codes, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with licensee and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC809 (FAS) - (06/04)
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