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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601249
Report Date: 05/23/2022
Date Signed: 05/23/2022 10:40:27 AM

Document Has Been Signed on 05/23/2022 10:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ADULT BASIC LEARNING ENVIRONMENT, INCFACILITY NUMBER:
197601249
ADMINISTRATOR:ROBERT MARTINEZFACILITY TYPE:
775
ADDRESS:204 N. VICTORY BLVD.TELEPHONE:
(818) 842-4933
CITY:BURBANKSTATE: CAZIP CODE:
91502
CAPACITY: 30CENSUS: 0DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Program Director She-ri GlendenningTIME COMPLETED:
10:47 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an announced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Program Director She-ri Glendenning and explained the purpose of the visit. Facility is an Adult Day Care program. The facility consists of single floor divided into various work areas including: Life/Vocational Skills area, Music room, Arts/Crafts room, Relaxation room, Kitchen and two (2) restrooms. Water temperature in the bathroom measured at 116.2 degrees and toilets observed operable.
The last fire drill was completed on March 2020. None since due to program being remote for last 2 years

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 has no designated isolation room as clients would not be allowed due to Covid positive.
· Five (5) activity rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Zero (0) centrally stored client medication records were reviewed as program is currently remote.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not present at time of visit as facility clients are all remote learning.
· Sufficient supply of non-perishable foods for 7 days was observed.
· A posted Emergency Disaster Plan was not observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies cited (see 809D for details)

Exit interview was conducted with Director She-ri Glendenning. A copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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Document Has Been Signed on 05/23/2022 10:40 AM - It Cannot Be Edited


Created By: Alberto Lopez On 05/23/2022 at 09:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ADULT BASIC LEARNING ENVIRONMENT, INC
FACILITY NUMBER: 197601249

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA and Program director observed 10 missing celing tiles, broken water facet in hallway, and 4 sections of the wall leading to back door with indents/damage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Licensee will replace broken facet, 10 celing tiles, and repair damage in the walls by POC date and send photos as proof to LPA
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022


LIC809 (FAS) - (06/04)
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