Facility Evaluation Report

An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator May Ballard. Purpose of the visit is stated. This is a San Gabriel Pomona Regional Center vendored facility Level IV-H.

LPA conducted physical plant tour inside and out at 12:35 PM. During the tour, LPA observed that the facility has bedrooms (6) bedrooms and three (3) bathrooms. Two (2) bedrooms and one (1) bathroom is designated for staff use, one (1) is being used as an office and the other as staff lounge. There is no body of water in the facility. This facility is fire cleared for four (4) ambulatory and two (2) non-ambulatory residents..

The front main door is the only entrance being utilized at the facility. Screening area is located upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

The facility had submitted and approved Mitigation and Infection Plan.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage.

Bedrooms were toured and observed to be clean and appropriately furnished.

Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 111.6°F to 113.8°F.

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition. (continued on LIC 809-C)