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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600156
Report Date: 01/11/2024
Date Signed: 01/11/2024 12:08:04 PM

Document Has Been Signed on 01/11/2024 12:08 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
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:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Annette Aguila- AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Annette Aguila, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (4) client medications, (4) client files, (3) staff files, and conducted interviews with (1) staff. LPA was unable to conduct interviews with clients due to clients being out of the home at the time of the visit. The facility is a single-story home, operating as an Adult Residential Facility. It is licensed to serve (4) developmentally disabled adults, ages 18-59. There is a fire clearance approved for (2) non-ambulatory clients. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review.
LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats for the shower. The hot water was tested and measured between 113*F-115*F, which is in compliance. Food supplies was observed and was sufficient as required. Emergency food supplies and water were available. First aid kit and manual were observed- available and complete. No bodies of water were observed on the premises. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to clients in care. The last fire drill was conducted on 01/01/2024. Smoke/carbon monoxide detectors were tested and operational. (4) client files and (3) staff files were reviewed and observed to be complete with all required documentation. (4) client medications were reviewed and were observed to be documented properly and given as prescribed.

Per California Code of Regulations, Title 22, no deficiencies were observed or cited, during today's visit.
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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