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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600156
Report Date: 01/21/2022
Date Signed: 01/21/2022 10:42:41 AM

Document Has Been Signed on 01/21/2022 10:42 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:KAISER SPECIALIZED RESIDENTIAL GLENDORAFACILITY NUMBER:
198600156
ADMINISTRATOR:AGNES AGUILAFACILITY TYPE:
735
ADDRESS:1620 AVON PLACETELEPHONE:
(626) 857-1827
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 4CENSUS: 4DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator, Annette AguilaTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Annette Aguila and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed staff and client files.

Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water was 107.9 degrees which is within the required 105 - 120 degrees. Cleaning supplies and chemicals are inaccessible to clients. PPEs are located in the garage. Facility has at least a 30-day supply of PPE. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. The common areas such as living room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. Signs are posted throughout the home to remind staff and clients to wear masks and wash hands. Staff were observed checking visitor's temperature at the time of entry.

LPA reviewed client files to confirm vaccinations and to confirm emergency contacts have been updated. LPA reviewed staff COVID-19 testing and confirmed staff working have fingerprint clearances. LPA reviewed 4 clients' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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