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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600156
Report Date: 12/27/2022
Date Signed: 12/27/2022 11:42:34 AM

Document Has Been Signed on 12/27/2022 11:42 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
GREATER LA AC/SC, 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:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Agnes Aguila, AdministratorTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an annual inspection with the focus on the Infection Control Domain. LPA Chan arrived unannounced and met with Administrator, Agnes Aguila. The purpose of the visit was stated. The facility is licensed for 4 Developmentally Disabled adults ages 18 through 59, of which two may be non-ambulatory. There are currently 4 clients receiving services from the San Gabriel/Pomona Regional Center. The facility has an approved mitigation plan in which they are still following.

The inspection consisted of the following:
  • The facility consists of 4 client bedrooms, 2 bathrooms, living room, dining room, kitchen, second living room used as the administrator office area, and an attached garage.
  • Screening and temperature are taken for clients, staff, and visitors upon entry.
  • COVID-19 signage were posted at the front door and throughout the home. LPA observed posters for hand washing in the bathrooms, covid-19 symptoms check, and cough/sneeze etiquette.
  • Clients have their own bedroom and are able to quarantine by themselves.
  • PPE supplies for at least 30-days are stored at the home.
  • Sharps and knives are stored in a security box and is locked under the kitchen sink.
  • Cleaning solutions and disinfectant sprays are locked in the cabinet inside the garage.
  • There were sufficient food supplies of 2-day perishable and a week of non-perishable observed.
  • Medications are locked and centrally stored in the second living room. LPA reviewed the medications for all 4 clients and they are being administered as prescribed and properly documented.
  • Fire extinguishers were observed to be fully charged and last inspected on 11/16/22.
  • Clients' emergency contact information are up-to-date.


LPA did not observe any deficiencies today. An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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