<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603438
Report Date: 06/10/2022
Date Signed: 06/10/2022 01:16:27 PM

Document Has Been Signed on 06/10/2022 01:16 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:NAGOMI HOME LLCFACILITY NUMBER:
198603438
ADMINISTRATOR:AYABE, TOKIEFACILITY TYPE:
740
ADDRESS:1128 N FAIRVALLEY AVETELEPHONE:
(626) 404-8798
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 2DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tokie Ayabe, LicenseeTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Tokie Ayabe, Licensee, who assisted with the visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly residents age 60 and above, approved for 6 non-ambulatory residents. The facility has two (2) Hospice Waiver on file. Annual licensing fees are current. LPA discussed the purpose of today's visit.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is a two-story building consisted of: first floor, there are four (4) resident rooms, office, activity room, living room, laundry area, kitchen, four (4) resident bathrooms, and dining room; second floor, there are four (4) staff rooms and two (2) staff bathrooms. Residents' medications were centrally stored in the office, locked and the records are current. Hazardous items are locked and inaccessible to residents in care. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. Resident bedrooms had furniture, lighting fixtures and personal storage space as required. Mattress pads were observed on all beds. Sufficient amount of linen were also observed. Bathrooms inspected were clean, operable, and furnished with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 116.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Last fire drill was conducted on 1/19/22. Administrator certificate is current and expiration date is 05/27/23.

Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean. Sufficient supplies of plates, cups, glasses and utensils for the current census was observed. A comfortable temperature of 74 degrees Fahrenheit maintained throughout the entire facility.

(- continued in LIC 809 C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: NAGOMI HOME LLC
FACILITY NUMBER: 198603438
VISIT DATE: 06/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A dual device of smoke detectors combined with carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. All mandated documents and signages were posted in common areas. There was a shaded outdoor area with ample seating. No bodies of water observed.

No deficiencies were cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Licensee, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2