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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593695
Report Date: 02/06/2023
Date Signed: 02/06/2023 01:29:32 PM

Document Has Been Signed on 02/06/2023 01:29 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:
02/06/2023
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Stephanie KaplanTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Elizabeth Irra and Tena Herrera conducted a visit for a capacity increase. This program is currently licensed with a capacity of 24 (building 8) and is seeking for an additional 34 individuals (building 5) for a total capacity of (58) between both buildings. The Fire Inspector approved the total for the capacity of 58 non-ambulatory clients between building 5 and building 8. LPA met with Stephanie Kaplan (Executive Director of Transition Program and Rehab Services), Linda Leyva (Director of Licensure and Accreditation) and Rachel Tran (Clinical Director).

This program operates Monday through Friday 9AM to 3PM. This building (building 5) consists of a main activity room (also used as a lunch room), small therapy gym, private treatment room, conference/classroom, staff offices, (5) client bathrooms (4 multi stall bathrooms and 1 individual) and (2) staff bathrooms.

LPAs observed the following:
  • COVID signage posted throughout the building.
  • PPE supplies stored. Additional PPE supplies available at the hospital (same campus).
  • Client Rights are posted.
  • Let us No poster posted.
  • Emergency Disaster plan is posted (LIC 610D). Emergency Disaster plan is readily available.
  • Facility had comfortable room temperature.
  • Facility telephone available for client use.
  • Bathrooms: water temperatures: bathrooms #114 and #115 measured at 113.9* and bathrooms #108, #109 and #110 measured at 114.0*. Hand washing signs and paper towels observed inside all bathrooms. Signal systems tested and operable. Grab bars observed.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SERVICES
FACILITY NUMBER: 191593695
VISIT DATE: 02/06/2023
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  • Carbon monoxide: tested and operable.
  • Fire alarm: tested and operable.
  • Fire extinguishers: serviced on 02/05/23 and appear to be full.
  • Food: lunch is provided to clients during programming hours. Food is prepared and delivered by the campus cafeteria.
  • Client files: stored in building 5 (Administrative Office).
  • Money handling: none.
  • Chemicals: locked inside the environmental services closet.
  • Water supply: drinking faucet on premises.
  • Therapy gym and/or small therapy room will be used for clients that are feeling ill and awaiting to be picked up.
  • Storage pace for clients items observed.
  • Outdoor space has appropriate shading.


No deficiencies noted. Exit interview conducted, appeal rights and a copy of this report was provided to Stephanie Kaplan.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC809 (FAS) - (06/04)
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