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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610397
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:34:40 PM

Document Has Been Signed on 08/21/2024 01:34 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ICON-ADPFACILITY NUMBER:
197610397
ADMINISTRATOR/
DIRECTOR:		BROWN, DEWALTFACILITY TYPE:
775
ADDRESS:2369 LINCOLN AVETELEPHONE:
(626) 926-3519
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 120CENSUS: 74DATE:
08/21/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Assistant Administrator (AA), Steven James and Administrator, DeWalt Brown TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced Annual Required – continuation visit to this Adult Day Program. Upon arriving at the facility, LPA and LPM met with Assistant Administrator (AA), Steven "Shay" James and Executive Director (ED), DeWallt Brown and explained the reason for the visit.

At 09:30a.m. LPA, LPM and ED tour the physical plant for compliance with safety, maintenance, and operational requirements. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
During initial annual inspection conducted on 07/19/2024 LPA Alvizar- Ettima conducted a physical plant tour at 11:00am,

The facility has fire clearance for 120 clients of which 20 may be non-ambulatory. The facility is a one (1) story building located in a commercially zoned neighborhood. The Adult day Program is used by the clients for recreation, educational and life skills purposes. It serves clients with developmental disabilities and intellectual disabilities (DD/ID).

There is one entrance being utilized at the facility, there are required posters thought the facility. Smoke detectors were tested and function properly. Facility disaster drills was conducted on 07/12/2024. Smoke alarms are hardwired and interconnected. There is a pull system in place. There is a carbon monoxide detector installed in the facility. There are three (3) fire extinguishers located all over the area, last inspected 03/01/24.

Potentially dangerous items toxic, cleaning agents and tools are locked in the garage at the back parking area inaccessible to clients. Hot water temperature measured between 106.1 - 114.0 degrees Fahrenheit (F) which are within the required range for client comfort and safety.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ICON-ADP
FACILITY NUMBER: 197610397
VISIT DATE: 08/21/2024
NARRATIVE
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Kitchen: There is no requirement in the Day Program to maintain a one-week supply of nonperishable, and two day supply of perishable food, although emergency water is maintained on the premises. The kitchen is for staff use only. LPA observed plenty of snacks in the facility.

Bathrooms: LPA observed three (3) bathrooms to be clean, properly supplied, functional fixtures and one (1) hand sanitation sink located in the main area. All toilets are ADA (American with Disabilities Act) compliant. There is a shower in the unisex restroom located in the back area that can be used to bathe clients if needed.



Common Areas: There are five (5) customizable classroom/activity areas. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair. At 11:30a.m. LPA observed clients watching a movie in the reception area visible to staff office.

Surrounding Grounds (Outdoors): Fully fenced and gated outdoor. There was a shaded area with proper furniture for outdoor use in the back of the facility. There are no bodies of water and firearms on the premises.
LPA Alvizar-Ettima also observed surveillance cameras installed in the classrooms as well as in the common areas.

At the time of this visit during an inspection, LPA and LPM observed that the door leading to the barber shop was removed and the barber shop was separated from the facility with the wall. The window between the rooms also was blocked with the solid drywall.

Alteration to existing building and violation of existing approved fire clearance was previously discussed with ED on 07/19/2024 and he was advised to request a new fire inspection and contact the department of building and safety prior to alteration of existing building.

Prior to Annual continuation visit the ED submitted a new facility sketch to identify changes and to get a new fire clearance. However, the Department was not informed that they made an alteration to existing building by completely blocking the door and building the wall to separate barber shop from the facility.

During inspection LPA and LPM were able to hear loud noises coming from the barber shop that may potentially affect the clients while they are in adjacent room participating to specific activities.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2024 01:34 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 08/21/2024 at 12:38 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ICON-ADP
FACILITY NUMBER: 197610397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82020
82020 Fire Clearance All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by;
Deficient Practice Statement
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Based on inspection and observation the licensee did not comply with the section cited above. While making alteration to existing physical plant, one of the facility exits is blocked and physical plant no longer meets approved fire clearance. This possess an immediate health and safety risk to clients in care.
POC Due Date: 08/22/2024
Plan of Correction
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Within 24 or next business day of the licensing department, the Licensee will submit written plan if action explaining the steps they are going to take to comply with Title 22 Regulations pertaining approved fire clearance.
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:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2024 01:34 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 08/21/2024 at 12:49 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ICON-ADP
FACILITY NUMBER: 197610397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068
82068 Admission Agreements (a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any. (c) Agreements shall be dated and signed, acknowledging the contents of the document, by the client and the client's authorized representative and the licensee/designated representative, no later than seven calendar days following admission.This requirement is not met as evidenced by. The facility did not comply with the section to maintain admission agreements for facility clients.

Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The admission agreements in 74 out of 74 clients were missing which posess a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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Licensee will inform in writing how they are going to comply with the Section 82068 to
ensure that facility retains approved and signed admission agreement for each client.
Type B
Section Cited
CCR
82086
82086 Alterations to Existing Buildings or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement is not met as evidenced by;
Deficient Practice Statement
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Based on inspection and observation, the licensee did not comply with the section cited above. The licensee made alteration to the existing facility without prior notification to the Licensing Office. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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Licensee will submit new facility sketch including the sketch for the backyard/parking, identifying recent changes made to physical plant. In addition written statement will be provided explaining when and how the facility will obtain approved permits for alteration of exisiting bulding as needed.
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:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ICON-ADP
FACILITY NUMBER: 197610397
VISIT DATE: 08/21/2024
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In addition, during this inspection LPA and LPM discussed the facility program plan and ED stated that they are no longer providing some of the activities identified in their program plan. LPM Margaryan advised ED that the changes made to the program plan including the information regarding the usage of surveillance cameras must be provided to the Licensing Department for review and approval.

The Licensee/ED also agreed and understood based on recent changes, made to the physical plant, they should request new fire clearance, and inquire permits from the local Building and Safety Department as needed.

Based on overall inspection, observation and the discussion, the following deficiencies were cited and recorded on LIC809D. In addition ED was informed that $500.00 Civil Penalty will be assess for operating in violation of secured fire clearance that previously was approved by the fire Department.

Exit interview conducted and copy of report provided to Executive Director.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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