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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603705
Report Date: 03/18/2024
Date Signed: 03/18/2024 01:39:01 PM

Document Has Been Signed on 03/18/2024 01:39 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:ACTIVE CARE HOMEFACILITY NUMBER:
198603705
ADMINISTRATOR:MORRIS, MELANIEFACILITY TYPE:
740
ADDRESS:1838 S RADWAY AVENUETELEPHONE:
(818) 274-1809
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 6CENSUS: 4DATE:
03/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joseph Jose - Licensee TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an announced pre-licensing visit using CARE Tool. LPA met with Licensee Joseph Jose and Operational Manager Daniel Adebisi and explained the reason for the visit. This Pre-Licensing Inspection is due to a change of ownership. The facility has an approved fire clearance to be licensed to serve five (5) ambulatory residents and one (1) bedridden resident. Hospice waiver granted for 6 clients.

The facility is a single-story home, located in a residential area, that consists of a living room, dining area, (4) resident bedrooms, (2) bathrooms, a kitchen, staff room, attached garage, and shaded patio with seating in the back yard. Laundry area observed in the garage.


A locked storage area for central storage of medications was observed in the dining area. A locked storage area in the garage for cleaning solutions and disinfectants was observed. Fire extinguisher was observed in the kitchen, and it is fully charged. Carbon monoxide / Smoke detectors were observed throughout the facility and were tested and operable. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris. No pools or bodies of water were observed in or around the home. Grab bars and non-skid mats were observed in the bathrooms. There are no firearms present at the facility. The first-aid kit was observed and is kept in the medication cabinet which included all required supplies. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Additional food supplies observed in the garage. Sharps and cleaning solutions are kept locked in a kitchen cabinet and in the garage.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ACTIVE CARE HOME
FACILITY NUMBER: 198603705
VISIT DATE: 03/18/2024
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The water temperature was tested in both bathrooms and measured at 114.1 degrees F and 114.7 degrees F, which is within the required 105-120 degrees F. Residents bedrooms have all required furniture, lighting, and bedding. There is closet space for clothing and other belongings. Extra clean linen was observed in the bedrooms.
Staff and client files are maintained locked in a cabinet located in the dining room area.
LPA conducted the Component III with the licensee. The Pre-licensing is complete, and the facility has no deficiencies.

Exit interview conducted and a copy of this report was provided to Licensee. 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.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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