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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600156
Report Date: 03/11/2024
Date Signed: 03/11/2024 10:10:03 AM

Document Has Been Signed on 03/11/2024 10:10 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:
03/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Annette Aguila- AdministratorTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of following up on a self-reported incident regarding a car accident with clients involved. LPA Maldonado met with Administrator, Annette Aguila, and explained the purpose for the visit.

The facility Administrator called the Monterey Park Regional office and submitted an incident report on 3/07/24 to report the incident. It was reported that on 3/06/2024, at about 9:55am, Clients#1-3 (C1-C3), and Administrator were in the company van, driven by Staff#1 (S1). Staff and clients were being taken to C1-C3's medical appointments. While on the road, another car cut off the company van, causing a collision. The van was pulled over and all passengers were checked for injuries. The vehicle sustained light damages to the front right bumper, dent on the right fender, and scratches on the right side mirror. Clients still made it to their medical appointments and were observed there for any changes. All clients stated to be okay and did not complain of any pain or injuries. Regional Center, corporate, and licensing were all notified of the incident. Clients refused to be taken to the emergency room or follow up with their primary care physician's. Total body checks for clients were conducted upon return to the facility with no visible injuries.

During today's visit, LPA Maldonado ensured S1 had a valid driver's license, the company vehicle is in good repair, and reviewed the facility vehicle's registration and insurance policy to ensure they are current and active. After review of S1's driver's license, it was confirmed that S1 has a current driver license, with expiration date of: 10/12/2025. The vehicle registration is valid until 01/18/2025 and insurance policy is valid until 06/18/2024. LPA inspected the vehicle and observed only scratches to the front right fender and the right side mirror. Administrator provided a copy the vehicle inspection report conducted on 3/07/2024, which indicates the vehicle has minimal damage and is okay to drive. No damage to the vehicle tires. LPA also verified that C1-C3 did not sustain any injuries due to the accident. During the visit, (2) of (3) clients were at the facility and were observed without visible injuries and did not appear to be in any pain.

No deficiencies were observed or cited during today's visit.
An exit interview was conducted and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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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