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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603313
Report Date: 07/01/2024
Date Signed: 07/01/2024 12:30:18 PM

Document Has Been Signed on 07/01/2024 12:30 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/
DIRECTOR:		NGO, ANTHONYFACILITY TYPE:
740
ADDRESS:333 TONOPAH AVE.TELEPHONE:
(626) 363-4343
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 6DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Anthony NgoTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff Lara and the purpose of the visit was discussed. Administrator Anthony Ngo arrived shortly after.
LPA completed the following domains:
1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. LPA observed and reviewed the infection control plan

2. Physical Plant/Environmental Safety: LPA toured the facility inside and out to ensure there are no health and safety hazards. The facility is located in a residential area. A tour of the single-story facility includes: Living room, family room, attached garage/laundry area, dining area, kitchen, 3 resident bedrooms, 1 staff bedroom and 2 bathrooms. Each residents' bathrooms are clean, sanitary and in a operable condition. LPA tested hot water temperatures and they were between 105 and 120 degrees F. which are within Title 22 regulation. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all working well. Each residents room have the required furniture, bedding and sufficient lighting and closet space. The facility have a telephone services in the premises.

3.Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Facility has a fire clearance for (6) total capacity of which (2) may be non-ambulatory. Liability Insurance reviewed and matches Licensing requirements.

4. Staffing: Sufficient staffing was observed during the visit. There is NOC shift staff scheduled for each day.

5. Personnel Record/Training's : The Administrator Anthony Ngo and administrator certificate is currently pending review for renewal. All the facility staff have criminal background clearance and associated with the facility and the required training. Four (4) staff files were reviewed. Required documents were observed.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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: TONOPAH HOME LIVING
FACILITY NUMBER: 198603313
VISIT DATE: 07/01/2024
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6. Residents Records-Incident Reports: A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.

7. Residents Right-Information: RCFE complaint poster and Personal rights were observed and its posted near the entrance and reception area.

8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.

9. Food Services: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. No modified diet plans are currently in place. LPA observed all food to be stored properly.

10. Incidental Medical and Dental Services: Six (6) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.

11. Disaster Preparedness: The facility has a Emergency and Disaster Plan. Plan is reviewed yearly by Administrator. LIC 610e was observed and reviewed by LPA.

12. Resident with Special Health Needs: There are currently no residents receiving home health services. There are no residents receiving hospice care. No postural support residents currently reside in the facility. No half bed or full bed rails were observed in resident rooms. Individual Service Plans and Appraisals are on File. No residents have prohibited health condition.

No deficiencies were observed during the annual inspection. Exit Interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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