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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593695
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:27:54 PM

Document Has Been Signed on 01/17/2023 03:27 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA COLINA TLC/POST ACUTE BRAIN INJURY SERVICESFACILITY NUMBER:
191593695
ADMINISTRATOR:STEPHANIE KAPLANFACILITY TYPE:
775
ADDRESS:255 EAST BONITATELEPHONE:
(909) 596-0955
CITY:POMONASTATE: CAZIP CODE:
91769
CAPACITY: 24CENSUS: 24DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Stephanie KaplanTIME COMPLETED:
03:34 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility with focus on the infection control domain, LPA Lopez met with the Administrator Stephanie Kaplan and explained the reason for the visit. The facility is an Adult Day Program (ADP) licensed to accommodate 24 adults with Traumatic Brain Injuries (TBI). The program consists of 1 large single-story building, that includes: lobby, several office rooms, 5 restrooms, large therapy/exercise room, kitchen area, gym, laundry room, and outdoor plant.

The following were observed/inspected:



· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not have one designated isolation room as clients do not reside at day program.
·, Common areas, bathrooms, and outdoor physical plant was inspected.
· Facility is equipped with alcohol-based hand sanitizer.
· Zero (0) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· All clients were observed wearing masks.
· Food is not stored at facility
· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.

No deficiencies cited per Title 22 Health and safety code.

Exit interview was conducted with Administrator Stephanie Kaplan. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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