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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603538
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:10:39 PM

Document Has Been Signed on 03/21/2022 02:10 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:ALL IN CAREHOMEFACILITY NUMBER:
198603538
ADMINISTRATOR:YAMASHIRO, SHELLYFACILITY TYPE:
740
ADDRESS:1158 BEAVER WAYTELEPHONE:
(626) 698-9615
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 6CENSUS: 5DATE:
03/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Shelly Yamashiro - Applicant TIME COMPLETED:
11:45 AM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an announced pre-licensing visit at the facility. LPA Flores met with Shelly Yamashiro Applicant and explained the reason of the visit.

Facility has a fire inspection clearance conducted on 12/15/21 for 5 non-ambulatory and 1 bedridden residents over the age of 60 years old. Facility is a single home located in a residential area and has 4 resident rooms, 2 bathrooms, a kitchen, a dining room, a living room, a backyard, and an attached garage/laundry. No large bodies of water were observed. Facility has a fire sprinkle system and smoke detectors were observed and tested throughout the facility. A carbon monoxide was observed by the entrance and in working condition. Facility has sound device system in all exits.

LPA Flores conducted a tour with Shelly Yamashiro Applicant and observed the following:
Living room: has sufficient sitting area, and activities available.
Kitchen: sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies were observed under sink's cabinet not locked. Knives and sharps were observed in a drawer next to stove not locked.
Dining room: social distance is observed during meals and activities. Medication cabinet was observed not locked.
Bedrooms: All bedrooms have the required furniture, bedding, and medical request for half bed rails, signs for oxygen in bedroom.
Bathrooms: Have the required grab bars, toilet is working condition, hand washing sign visible, and soap and paper towels provided. Bathroom #1 has skid mat and water temperature was tested at 118.1 degrees F. and bathroom #2 was missing a skid mat/grips and water temperature was tested at 116.6 degrees F. which is within the required 105-120 degrees F.
Facility has hygiene products for residents, additional linens were observed. Emergency kit was observed and has all required items. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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: ALL IN CAREHOME
FACILITY NUMBER: 198603538
VISIT DATE: 03/21/2022
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Files were reviewed for 5 residents, resident #1 and #4 were missing a yearly Physician's Report. Medication was reviewed for 5 residents and all supplements medication for each resident was not labeled per physician's request. 5 staff files were reviewed.

Component III was conducted with applicant Shelly Yamashiro.

Applicant must correct the following items within 7 days of today's visit and submit pictures of corrections or documents:

Applicant must ensure all medication is lock and inaccessible to residents in care.
Applicant must ensure all knives, sharps are lock and inaccessible to residents.
Applicant must ensure all cleaning supplies are lock and inaccessible to residents.
Applicant must ensure residents in care have a current Physician's Report.
Applicant must provide a shaded area outdoor.
Applicant must ensure that passage way in the side of the house is kept free of debris and animal feces.
Applicant must ensure that bathroom #2 has a skit mat in the shower.
Applicant must ensure all medications (supplements) are labels per doctor's request and instructions.

Exit interview was conducted with applicant and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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