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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603532
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:09:58 PM

Document Has Been Signed on 03/01/2022 01:09 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:CHALET TERRACE SENIOR LIVINGFACILITY NUMBER:
198603532
ADMINISTRATOR:PALOMINO, AMANDAFACILITY TYPE:
740
ADDRESS:1064 CHALET TERRACETELEPHONE:
(323) 353-1164
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 0DATE:
03/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Amanda Palomino, licenseeTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an announced visit on 3/1/2022 for purpose of a pre-licensing evaluation. LPA met with Applicant, Amanda Palomino along with Boris Palomino.

An application was submitted to CCLD on 10/18/2021, for an initial license for a Resident Care Facility for the Elderly to serve the Elderly, 60 years and older. The requested capacity is for 6 residents, of which 6 may be Non-Ambulatory. The hospice waiver is approved for 4 residents. Component III was also completed during this visit.

LPA Chan toured the entire facility and observed the following:

A single story home that consists of 4 bedrooms (3 bedrooms for residents and 1 for staff), 2 bathrooms (1 in bedroom #1 and 1 for communal use), living room, dining area, laundry area, kitchen, and detached garage. The fireplace in the living room is adequately screened but will not be utilized per licensee. The facility has video surveillance without audio throughout the facility. Each exit door has an auditory device to alert staff upon opening. The spacious outdoor area consists of a shaded area for residents and is enclosed by walls and gates with latches. Passageways and doors are not obstructed. There are no swimming pools or bodies of water. The bedrooms are equipped with the adequate lighting, closet space, drawers, and chair. LPA observed a bed in 2 bedrooms and per licensee, she will provide beds to residents if they do not bring their own. Night lights are maintained in the hallways. The hot water temperature was measured between 105-120 degree Fahrenheit for both bathrooms and non-skid strips were observed. Extra bath towels, hand towels, wash cloths, blankets, bed linens were observed. Knives and sharps are locked and stored in the kitchen cabinet. Disinfectants and cleaning solutions are locked in the laundry area. The kitchen area consists of a refrigerator, microwave, and stove which are functional. Sufficient dishes and utensils were also observed.

(Continue on LIC809C)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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: CHALET TERRACE SENIOR LIVING
FACILITY NUMBER: 198603532
VISIT DATE: 03/01/2022
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Per applicant, the perishable items will be purchased prior to receiving first client. Emergency disaster plan, Personal Rights, Resident Councils Complaint procedures, along with the post labor information are posted on the board by the front door. There are smoke/carbon monoxide combo detectors are in the residents' rooms and living room and are operational. The fire extinguisher is fully charged and inspected on 2/23/22. The medications will be stored and locked in the kitchen cabinet. Staff and resident files will be maintained at the facility and will be secured in a locked file cabinet.

The facility phone number is (626) 872-1968.

Component III was conducted today and information was provided about how to operate the facility within substantial compliance. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit

An exit interview was conducted and a copy of this report has been furnished to the applicant.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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