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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603313
Report Date: 06/08/2021
Date Signed: 06/08/2021 02:12:56 PM

Document Has Been Signed on 06/08/2021 02:12 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:TONOPAH HOME LIVINGFACILITY NUMBER:
198603313
ADMINISTRATOR:NGO, ANTHONYFACILITY TYPE:
740
ADDRESS:333 TONOPAH AVE.TELEPHONE:
(626) 363-4343
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 5DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jossen MaglalangTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPAs) Elizabeth Irra and Nina Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with Jossen Maglalang and explained the purpose of the visit. LPAs toured the facility premises.

This home consists of 4 bedrooms, 2 baths, kitchen, dinning area, living room, family room and attached garage. There are (5) clients residing at this home. All clients receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this home and in common areas.
  • Four (4) client rooms were inspected.
  • Medications for (5) clients were reviewed.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • Clients were socially distanced according to local public health guidelines.
  • Additional PPE supplies are stored inside the garage and staff room and are easily accessible.


There are no deficiencies noted.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Ms. Maglalang.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2021
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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