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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603302
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:14:33 PM

Document Has Been Signed on 02/06/2025 04:14 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:SUMMIT VIEW HOME CAREFACILITY NUMBER:
198603302
ADMINISTRATOR/
DIRECTOR:
CASTRO, SILVIAFACILITY TYPE:
740
ADDRESS:107 CLEARVIEW CREST DRTELEPHONE:
(909) 396-7839
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
02/06/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Theresa Kuwashima, StaffTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a follow up visit to continue the annual inspection. LPA met with Administrator, Silvia Castro. The initial visit was on 1/31/25.

During the visit today, LPA inspected the rest of the domains of the CARE tools.
Staffing: Per the administrator, there is sufficient staffing at the facility and backup staff if needed. Staff employed have fingerprint clearance and associated to the facility.
Personnel Records-Training: LPA reviewed 3 staff files and all documents are in file. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement.
Resident Records-Incident Reports: LPA reviewed 6 resident files and the following documents are found - admission agreements, Identification & Emergency Information, Physician's Report, Consent forms, Resident rights, Safeguards for Property/Valuables form.
Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are
sufficient supplies and equipment to meet resident's physical/mental capability. Staff encourage residents to participate in activities.
Incidental Medical & Dental: The medications are centrally stored and locked in the cabinet. All 6 resident medications were reviewed and marked in the Medication Administration Record (MAR) log when given.
Resident with Special Needs: There are currently no residents with any prohibited or restricted health conditions or using oxygen.

No deficiencies are issued today. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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