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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603553
Report Date: 04/20/2022
Date Signed: 04/20/2022 02:22:28 PM

Document Has Been Signed on 04/20/2022 02:22 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:TIMERS RESIDENTIAL CAREFACILITY NUMBER:
198603553
ADMINISTRATOR:WILLIAMS, SHAUNA LVNFACILITY TYPE:
740
ADDRESS:452 PEMBROOK AVENUETELEPHONE:
(424) 457-9771
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 6CENSUS: 0DATE:
04/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shauna WilliamsTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Elizabeth Irra and Associate Governmental Program Analyst (AGPA) Michael Monriel II conducted a pre-licensing visit.. LPA met with Shauna Williams (Applicant). The facility is to serve 6 ambulatory individuals over the age of 60. This is a 2 story home which consist of (3) bedrooms, (2) baths, living room, kitchen, dining area, office (upstairs) and an attached garage with the laundry unit. Component III was also completed during this visit.

The following was observed/inspected:

  • Smoke detectors operate properly.
  • Carbon monoxide detector was tested and operable. Located near the garage door. No carbon monoxide in the upstairs section of the home.
  • Fire extinguisher is located in the kitchen.
  • Cleaning solutions and sharps are locked in the kitchen under the sink.
  • Building and grounds are free from hazards.
  • Beds have the required linen/supplies.
  • Mattresses and bedsprings are in good repair.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
  • Residents have the appropriate furniture (one chair, night stand, adequate lighting for each client adequate closet and drawer space). Note: This home was set up for 4 residents and not 6 as noted on the application. Applicant to set home up for 6 Residents.
  • There are enough bath towels, hand towels and wash cloths for all Residents.
  • Sufficient amount of personal hygiene supplies available for Residents.
  • There are sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by Residents. ***Refer to LIC 809C for the continuation of this report***
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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: TIMERS RESIDENTIAL CARE
FACILITY NUMBER: 198603553
VISIT DATE: 04/20/2022
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  • Facility has a washer and dryer that are fully operational located inside the garage,
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two day supply of perishables available, seven day supply of non-perishable available.
  • Dining table had 4 chairs versus 6 chairs.
  • Pesticides and other toxic substances are stored and locked away from food supply. They are locked and stored under the kitchen sink.
  • There is a designated space inside the closet (near the dining area) for Medications to be locked. Client and staff files will be stored and locked.
  • First Aid Kit inspected. Scissors missing. Current First Aid Manual missing.
  • Physical plant is in good repair.
  • Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly.
  • Outdoors: there is a shaded area set up in the backyard to accommodate 6 Residents.
  • Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly.
  • Resident Personal Rights are posted.
  • Emergency Disaster Plan posted.
  • COVID-19 signage to be emailed to Applicant (by LPA Irra) for posting.

The Applicant to correct the following by 05/07/2022 (Applicant to submit pictures):
  • Water supply: Hot water temperature measured between 125.0* to 126.5. Title 22, 87303
  • Bathroom: Grab bars missing in the bathtubs/showers of both bathrooms. Title 22, 87303
  • Night light: Missing in the hallway. Title 22, 87307
  • Bedrooms: To be set up for (6) Residents as noted on Application. Currently set up for (4) Residents. Title 22, 87307
  • Complaint Poster:Complaint poster to be posted (20”x 26”) Heath & Safety Code 1569.33(h)(2)
  • First Aid Kit and Manual: Kit missing scissors. Current manual missing. Title 22, 87465

Exit interview conducted and a copy of this report was provided to Shauna Williams (Applicant).

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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