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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603521
Report Date: 12/22/2021
Date Signed: 12/22/2021 12:46:20 PM

Document Has Been Signed on 12/22/2021 12:46 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:A PEACEFUL HOME OF COVINAFACILITY NUMBER:
198603521
ADMINISTRATOR:BUGASTO, MYRNA G.FACILITY TYPE:
740
ADDRESS:16025 E BRIDGER ST.TELEPHONE:
(626) 244-9999
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 0DATE:
12/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Thang Duong, ApplicantTIME COMPLETED:
01:00 PM
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 Licensing Program Analysts (LPAs) Hanna and Tao conducted an initial Pre-licensing visit and met with Applicant Thang Duong, Applicant secretary Janice Jabonero and House Manager Jeremias Jabonero who assisted with the walk-through. Per Thang, he will be the primary Administrator at the facility. This is an initial application applying for dementia program.

A component III was conducted during the visit. There are currently 0 residents living in the facility. The fire clearance has been approved for 5 non ambulatory and 1 bedridden. All (5) bedrooms have been cleared for non-ambulatory clients and bedroom # 3 is cleared for bedridden. The physical plant was toured and the following was observed.

This facility is located in a residential neighborhood, single story house, with (5) bedrooms, (1) bathrooms, living room, dining area, kitchen, and a car garage. The facility has (4) single rooms and (1) shared room for clients. There will be no live-in staff at the facility.

Appliances in the kitchen such as dishwasher, microwave, stove and oven were observed to be clean and operational. The washer and dryer are located inside the garage.

Living room has required furniture. Dining room has a table and (4) chairs and a bench for a total seating of (6). There is a fireplace located in the shared bedroom (#1) and observed to have gas disconnect with gas control removed.

Resident rooms were observed to have the required furniture such as bed frames, dressers, chairs and sufficient closet space. Bedrooms also have the required bedding sheets. The bathrooms have operational showers, hand washing sinks and toilets.
(Continued on a LIC 809-C)
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Joseph Hanna
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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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: A PEACEFUL HOME OF COVINA
FACILITY NUMBER: 198603521
VISIT DATE: 12/22/2021
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The smoke alarms and carbon monoxide detectors were tested and observed to operating properly. The facility has (2) fire extinguishers located in the kitchen/dining room.

The facility has central air conditioning at a set temperature of 76 degrees. There is sufficient lighting throughout the home. There are no security bars on the windows. There were no obstructions observed on the premises. The home has all the required posters posted. Resident and staff files were not reviewed since there are no residents living in the facility. First aid is complete with manual.

The backyard has a shaded patio area with patio furniture.

LPAs observed corrections required:

Interior:
-Medication cabinet with no key lock.
- Kitchen drawer containing sharp objects (knives, scissors and etc) with no key lock.
- Water heater closet unsecured
- Cleaning supply, linen, and toxin closet on far end of hall is unsecured.
--> All areas listed above will need to be secured with a key lock.

- 5 bedrooms have key lock doorknobs (Applicant will need to switch to keyless doorknobs)
- Fire door leading to 4 resident bedrooms/bathroom has dead-bolt (applicant to remove dead-bolt)
- Unsecured toxins and gardening tools found in backyard (Applicant to secure all items)
- Sliding screen leaning on wall (install or replace)
- No auditory alarm on sliding glass door leading to backyard
- Insufficient supply of linen, bed sheets, blankets, pillows, and towels
- Hot water temperature at 122 degrees Fahrenheit.

Applicant shall submit pictures to LPA as proof of correction via email/fax by 01/05/2022.

An exit interview was conducted with Applicant and copy was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Joseph Hanna
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
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