<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593695
Report Date: 02/02/2024
Date Signed: 02/02/2024 12:27:28 PM

Document Has Been Signed on 02/02/2024 12:27 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: 58CENSUS: 35DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rachel Tran and Linda LeyvaTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Rachel Tran (Clinical Director) and Linda Leyva (Director of Licensure and Accreditation) and discussed the purpose of today’s visit.

This program is currently licensed for a capacity of 58 non-ambulatory clients between building 5 and building 8. This program operates Monday through Friday 9AM to 3PM.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an Infection Control Plan in place.

Physical Plant & Environment Safety: Carbon monoxide observed. Fire extinguishers observed throughout the premises (last serviced on 01/15/24). Water temperature measured between 107.0* to 113.0*. Filtered drinking water is available for clients. AED located near the gym (last serviced on 01/16/24). AED (label) indicates it is to be installed before 05/2028.

Operational Requirements: Staff are adhering to operational requirements. Fire clearance approved for a capacity of 58 non-ambulatory clients between building 5 and building 8.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 02/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Personnel Records-Training: LPA reviewed staff files for Staff #1 (S-1) through Staff #4 (S-4). Staff have current First Aid/CPR/BLS certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff training records were also reviewed which revealed that staff have adequate hours of training. Staff files reviewed have current certification on either Physical Therapy, Speech Therapy or Occupational Therapy.

Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Needs and Services Plan/Service Plan, Program Rules, and Client Rights were observed.

Food Service: Pesticides and other similar toxic substances are not stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

Health Related Services: Per Ms. Tran- there are no clients that consume medication during programming hours.



Incidental Medical Services: Per Mr. Tran-there are (0) clients on a restricted health plan.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place. This program also has an Environment of Care (EOC) plan in place. The last disaster drill was conducted on 12/20/23.

Exit interview, appeals rights and a copy of this report was provided to Rachel Tran.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2