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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603538
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:02:42 PM

Document Has Been Signed on 05/11/2022 02:02 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: 3DATE:
05/11/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shelly Yamashiro - Applicant TIME COMPLETED:
02:15 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a announced case management visit to follow up on corrections needed during pre-licensing visit conducted on 3/21/22. LPA Flores met with applicant Shelly Yamashiro and conducted a tour to review corrections, reviewed resident's files and medication.

During today's visit LPA Flores conducted a tour with applicant Shelly Yamashiro and observed the following corrections:

LPA observed all medication lock and inaccessible to residents in care.
LPA observed all knives, sharps lock and inaccessible to residents.
LPA observed all cleaning supplies lock and inaccessible to residents.
LPA reviewed residents files and observed current Physician's Report for each resident.
LPA observed a shaded area outdoor.
LPA observed passage way in the side of the house is kept free of debris and animal feces.
LPA observed bathroom #2 has a skit mat in the shower.
LPA reviewed medications (supplements) and observed labels per doctor's request and instructions.

Component III of the application process was conducted on 3/21/22.

Facility meets Title 22 Regulations for physical plant.

Exit interview was conducted with Shelly Yamashiro and a copy of this report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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