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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603317
Report Date: 06/01/2021
Date Signed: 06/01/2021 04:45:52 PM

Document Has Been Signed on 06/01/2021 04:45 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:VINE RESIDENCEFACILITY NUMBER:
198603317
ADMINISTRATOR:LOPEZ, LORRAINEFACILITY TYPE:
740
ADDRESS:1405 E. VINE AVETELEPHONE:
(626) 890-7634
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 5DATE:
06/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Lorraine LopezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst Jose Villalobos conducted an unannounced Annual Inspection for Domain focused on Inspection Control. LPA was assisted by Administrator Lorraine Lopez

The facility is licensed as a Residential Care Facility for Elderly. The facility is a single story home licensed for (6) residents (5) may be non-ambulatory and (1) may be bedridden and approved hospice waiver up to (4) residents. There are (6) total rooms and (3) total bathrooms. The facility was adequately furnished, including the dining room, activity room, outdoor shaded patio. LPA observed rooms #1-6. Each bedroom had the required, furniture, fixtures, equipment and supplies. Including complete set of bedding, linen supply, hygiene supply, storage space, lighting. The smoke detectors and the carbon monoxide detector were tested and are operational. LPA observed the facilities food supply. 30-Day supply of PPE's were observed. Medications, cleaning solutions, toxins, knives are locked and inaccessible to clients. First aid kit observed. Required posting for social distancing and infection prevention guidelines in place were observed. Body of water was inaccessible to residents and fenced in. Training on covid-19 infection prevention observed. Yard is free of debris. Exits and passageways are free of obstructions. Facility is following Covid-19 guidelines and recommendations. Mitigation plan was approved 5/14/2021.

Files Reviewed:
LPA Villalobos reviewed two (2) staff files and all had the following: Health screenings with TB information was also present. All staff files reviewed also had criminal record clearances and are associated to the facility. Two (2) staff files reviewed have current first aid certificates and proof of training on file. Health screenings with TB information was also present. Two (2) client Medication Charts was reviewed. There were no issues with medication observed. The last disaster drill was conducted on 4/21. The facility's annual fees are current and paid.

No deficiencies were cited on todays visit using the Inspection Tool. Exit interview was conducted with Administrator Lorraine Lopez
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2021
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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