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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603021
Report Date: 02/28/2025
Date Signed: 02/28/2025 12:14:25 PM

Document Has Been Signed on 02/28/2025 12:14 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAMILY HOME LLCFACILITY NUMBER:
198603021
ADMINISTRATOR/
DIRECTOR:		VILLALVA, JOEL HFACILITY TYPE:
740
ADDRESS:1629 CALLE CIERVOTELEPHONE:
(626) 354-0265
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 1DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Joel Villalva/S-1TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an annual inspection visit. LPA met with Joel Villalva/S-1 and discussed the purpose of today’s visit.

This home is a single-story home with (5) bedrooms, (3) bathrooms, kitchen, dining area, living room and an attached garage. The fire clearance is approved for (6) non-ambulatory residents, of which (1) may be bedridden. This home also has an approved Dementia Care Plan and a Hospice Waiver approved for (2) residents. There are currently no residents receiving hospice care nor any residents are bedridden. Mr. Villalva showed LPA proof of the required liability insurance and will be e-mailing a copy of the insurance coverage to LPA.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an Infection Control Policy in place and was observed to be posted.

Operational Requirements: Facility is adhering to the operational requirements.

Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detectors observed. The fire extinguisher is located in the kitchen, hallway and garage and were last serviced on 01/08/25. Bathrooms have non-skid surfaces and grab bars.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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: FAMILY HOME LLC
FACILITY NUMBER: 198603021
VISIT DATE: 02/28/2025
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Staffing: Facility is adhering to staffing requirements.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 and Staff #2. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Resident Rights-Information: Resident rights are posted and are included in Resident files.

Planned Activities: Activity provides planned activities. This facility also provides internet access to the clients.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating.

Resident Records-Incident Reports: LPA reviewed Resident file for Resident #1 (R-1). Resident files are maintained at the facility. Resident file has the required documents. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment and Preplacement Appraisal Information, Resident Pre-Appraisal. Resident Rights were observed.

Disaster Preparedness: The facility has a Disaster Preparedness plan in place.

Health Related Services/Incidental Medical Services: The medications are stored and locked. Medications are administered as prescribed.

Exit interview conducted, copy of appeal rights and a copy of this report was provided to Joel Villalva/S-1.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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