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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603702
Report Date: 09/26/2023
Date Signed: 09/26/2023 11:34:12 AM

Document Has Been Signed on 09/26/2023 11:34 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:ST CECILIA'S SENIOR HOMEFACILITY NUMBER:
198603702
ADMINISTRATOR:VANDER POORTEN, TIFFANYFACILITY TYPE:
740
ADDRESS:1005 FOUNTAIN SPRINGS LN.TELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 0DATE:
09/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Tiffany Vander PoortenTIME COMPLETED:
11:41 AM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an announced pre-licensed visit and met with Administrator Tiffany Vander Poorten for the purpose of conducting a Pre-Licensing Inspection / Component III visit. This Pre-Licensing Inspection is due to change of location. This is the initial visit.

The facility has an approved fire clearance to be licensed to serve five (6) non ambulatory clients. The facility is a single-story home: 4 bedrooms, 2 bathrooms, dining/ living room, family room, backyard with locked storage shed, and attached garage located in Glendora, CA.

The physical plant was toured inside and out alongside Tiffany Vander Poorten. Pre-Licensed Inspection Tool was used.


he following was observed/inspected:

· There is a locked storage area that is centrally located for medication.

· Cleaning supplies are kept separate from food and located in a locked cabinet in the living room.

· Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.

· Fire extinguishers and smoke detectors operate properly.

· Doors and passageways are free of obstruction.

· There are no pools/bodies of water at the facility.

· Facility does not have firearms on premises.

· Facility sketch and sample menus.

· There is an emergency exiting plan with emergency phone numbers posted.

(Continued on 809D)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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: ST CECILIA'S SENIOR HOME
FACILITY NUMBER: 198603702
VISIT DATE: 09/26/2023
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· Facility has a current disaster and mass casualty plan maintained at the facility.

· There is a plan for employee accommodations and staffing arrangements.

· Operating telephone is on the premises and will be available to clients.

· First-aid supplies are maintained and readily available.

· Refrigerator and freezer were observed and are maintained at the correct temperatures.

· Food storage and preparation are clean and appropriate for food preparation.

· Hot water temperature was tested and is within the required range of 105-120 degrees F.

Component III was completed during today’s visit.

An exit interview was conducted, and a copy of this report has been furnished to Administrator Tiffany Vander Poorten.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

***LPA Lopez will verify bedroom furniture for residents prior to Licensure***

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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