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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603553
Report Date: 05/24/2024
Date Signed: 05/24/2024 11:11:49 AM

Document Has Been Signed on 05/24/2024 11:11 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:TIMERS RESIDENTIAL CAREFACILITY NUMBER:
198603553
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, SHAUNDAFACILITY TYPE:
740
ADDRESS:452 PEMBROOK AVENUETELEPHONE:
(424) 457-9771
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 6CENSUS: 4DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Shaunda WilliamsTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Elizabeth Irra conducted an annual inspection visit. LPA was allowed entry by Shaunda Williams. LPA discussed the purpose of today’s visit.
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This is a 2- story home which consist of (3) bedrooms, (2) bathrooms, living room, kitchen, dining area, office (upstairs) and an attached garage with the laundry unit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility does has an Infection Control Plan in place.

Operational Requirements: Facility is adhering to the operational requirements.

Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms tested and operable. Carbon Monoxide is located near the kitchen and it was tested and is operable. The fire extinguisher is located in the kitchen and appears to be full. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: 108.0*. Bathrooms had non-skid surfaces and grab bars.

Staffing: Facility is adhering to staffing requirements.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #3 (S-3). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

**Refer to LIC 809C for the continuation of this report.**

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TIMERS RESIDENTIAL CARE
FACILITY NUMBER: 198603553
VISIT DATE: 05/24/2024
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Resident Rights-Information: Resident rights are posted and included in Resident files.

Planned Activities: Activity schedule is posted.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating.

Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #4 (R-4). Resident files are maintained at the facility. Resident files have the required documents.

Disaster Preparedness: The facility has a Disaster Preparedness plan in place.



Residents with Special Health Needs:
Per Administrator, there are no residents with postural supports and no residents with prohibited health conditions. Per Administrator, there is (1) resident utilizing oxygen equipment and there is (1) resident under hospice care.

Health Related Services/Incidental Medical Services: The medications are stored and locked inside the closet near the dining area.


Exit interview conducted, copy of appeal rights and a copy of this report was provided to Shaunda Williams.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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