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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603532
Report Date: 02/14/2023
Date Signed: 02/14/2023 10:44:52 AM

Document Has Been Signed on 02/14/2023 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 4DATE:
02/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Gloria Lopez, StaffTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control domain. LPA arrived unannounced and was allowed entry by Staff, Gloria Lopez. The administrators, Amanda Palomino and Boris Palomino arrived shortly after to assist with the visit. The facility is licensed for 6 non-ambulatory residents ages 60 and above. The facility has an approved hospice waiver for 4 residents.

LPA toured the facility inside and out. There are no pools or bodies of water on the premises. There are a total of 4 bedrooms (3 bedrooms for residents and 1 designated for staff), 2 bathrooms, living room, dining room, kitchen, and detached garage. The backyard has a shaded area with table and chairs for residents to use. Staff are continuing to screen and take the temperature of visitors prior to entering. Staff and clients' temperature are also taken daily and documented. The facility has proper Coronavirus (COVID-19) signage at the main entrance and around the home. Hand washing signs are posted in each of the bathrooms and sink. Sufficient PPE supplies such as N95, surgical masks, gloves, and face shields are stored at the facility. Food supplies for 2 day perishable and a week of non-perishable were observed. Knives and sharps are locked. Cleaning supplies are stored and locked above the laundry machines. The facility has sufficient supplies of soap and paper towels. Medications are centrally stored and locked. LPA reviewed all 4 medications and did not observe any deficiencies. All staff on duty were wearing face masks. Per Administrators, they are still following the strictest COVID-19 guidance and also clean and disinfect at least once a day.

LPA did not observe any deficiencies during the visit today. An exit interview was held and a copy of this report was provided to Administrator Palomino.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
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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