198603590-9-8-2022-28-AS-BTAO-CJ3P2X-20220908105641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603590
Report Date: 09/08/2022
Date Signed: 09/08/2022 10:56:57 AM

Document Has Been Signed on 09/08/2022 10:56 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ALL FOR MOMS HOMECARE		FACILITY NUMBER:	198603590
ADMINISTRATOR:	TRUONG, PHUOC		FACILITY TYPE:	740
ADDRESS:	16136 E CLOVERMEAD ST.		TELEPHONE:	(626) 456-1066
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY: 6		CENSUS: 0	DATE:	09/08/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Phuoc Truong, applicant/administrator		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Tao and Ramirez, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPAs met with Phuoc Truong, applicant/administrator, who assisted with the visit. An application was submitted to CCLD on 05/25/2022. It is an initial application applying for Residential Care Elderly to serve elderly, ages 60 years old and older. The requested capacity is six (6) including five (5) non-ambulatory and one (1) bedridden. The applicant is D & P Homecare LLC and applied for dementia program. Fire clearance was approved on 7/8/22 and approved bedroom #2 for bedridden resident. Structure: Facility is a single house with six (6) resident bedrooms, two (2) bathrooms, living room, kitchen, backyard with shaded area, and laundry room. Passageways, walkways, driveways, steps and patios are free from obstructions. Bedrooms for Residents: Bedrooms are for six (6) residents including five (5) non-ambulatory and one (1) bedridden. The resident bedrooms are spacious and will easily accommodate the residents furnishings. Bathrooms: All bathrooms have a working toilet, wash basin, and shower with non-skid mat and grip bar. Linens & Hygiene Supplies: Beds have linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. ( - continued in LIC 809 C - )

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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 FOR MOMS HOMECARE	FACILITY NUMBER: 198603590
	VISIT DATE: 09/08/2022

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review at the entrance. Fire extinguishers located at kitchen mounted on the wall. First Aid kit and Red cross manual are in stock

Smoke Detectors: Carbon monoxide detectors and smoke detectors are dual and operable.

Appliances: Stove burners, oven, microwave, washer, and dryer are working.

Medications: Medication drawer is locked and available to staff but inaccessible to residents.

Issues were observed during the visit.
1) Water Temperature: Tested at 138.5 degrees Fahrenheit
2) Resident records: Stored in a cabinet but not locked
3) Alarm auditory devices at exits: Exits are not installed with alarm auditory devices.
4) Resident bedrooms: Mattress pads are missing in all residents room.
5) Resident bedrooms: No chair in residents' room
6) Side gate exits: Side gate exits were locked with a key lock. All key locks need to be removed.
7) Laundry room with cleaning compounds: cleaning supplies and water heater are stored in laundry room and accessible to residents. Laundry room needs to install a lock and inaccessible to residents.
8) Backyard: Water host on the ground which has trip hazard.

( - continued in LIC 809 C - )

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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 FOR MOMS HOMECARE	FACILITY NUMBER: 198603590
	VISIT DATE: 09/08/2022

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Applicant will provide the proof of Plan of correction (POC)by 9/13/22.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA Tao will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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