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 House Manager Al Ballard. Purpose of the visit is stated. This is a San Gabriel Pomona Regional Center vendored facility Level IV-C.

LPA conducted physical plant tour inside and out at 9:20 AM. During the tour, LPA observed that the facility has three (3) bedrooms and two (2) bathrooms. One (1) bedroom is designated for staff use. There is no body of water in the facility. This facility is fire cleared for six (6) ambulatory residents only.

The front main door is the only entrance being utilized at the facility. Screening area is located immediately 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 118.7°F to 119.8°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)