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Facility Evaluation Report

Jade Promised Home, La Puente01/09/2025Licence 198603789

Capacity4
Census0
Date signed01/09/2025 11:59:13 AM
The inspector’s account

Licensing Program Analyst (LPA) Jose Villalobos conducted an announced prelicensing visit with applicant Rhoderick Pereyra. Licensing received an initial license application for an Adult Residential Facility to serve up to (4) ambulatory clients on 6/10/24. Fire clearance was approved on 10/15/24.

The facility is a single story home with (4) bedrooms and (2) bathrooms. There is a front and back yard. Facility has an attached garage and detached shed for storage. LPA completed the visit using the following inspection tool domains:

Infection Control: Infection Control Plan was reviewed by LPA. Plan follows title 22 regulations

Physical Plant and Environmental Safety: Physical plant is in clean and good condition. Water temperature measured within regulation. Fire and CO2 detectors were tested and operational. Sharps and toxins are in locked areas. Required furniture was observed throughout the home.

Operational Requirements: Fire clearance approval was observed. Plan of operation was observed. Outdoor activity space and supplies for clients was observed.

Personal Records - Training: Locked storage space for staff files was observed. Mock files observed.

Client Records - Incident Reports: Locked Storage space for client files observed. Mock Files in place

Client Rights - Information: Requires posting observed regarding personal rights.

Food Service: 2 day perishable and 7 day non perishable supply was observed.

Health Related Services : First Aid Kit was observed

Disaster Preparedness: Facility has emergency disaster plan in place.

Component III was also completed at the time of this visit. The Physical Plant is cleared.

An exit interview was conducted, and a copy of this report has been furnished to Applicant Rhoderick Pereyra, 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

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction