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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600156
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:26:04 PM

Document Has Been Signed on 01/21/2025 04:26 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL GLENDORAFACILITY NUMBER:
198600156
ADMINISTRATOR/
DIRECTOR:		AGNES AGUILAFACILITY TYPE:
735
ADDRESS:1620 AVON PLACETELEPHONE:
(626) 857-1827
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 4CENSUS: 4DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:14 PM
MET WITH:Agnes Aguila, Admistrator TIME VISIT/
INSPECTION COMPLETED:
04:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required unannounced annual inspection. LPA met with Caregiver/House Lead Cherish Nicholson and explained the reason for the visit. Administrator Agnes Aguila showed up a few minutes later and assisted with the visit. The facility is licensed to serve 4 Ambulatory and 1 Non-Ambulatory Developmentally Disabled Adults ages 18-59. Facility currently has 4 Ambulatory clients serviced by San Gabriel/Pomona Regional Center.
The facility is a single-story home located in a residential area in Glendora, CA. A tour of the facility included living room, dining area, kitchen, 4 client bedrooms, 1 staff bedroom, 2 bathrooms, detached garage, staff office/laundry area, front yard, and back yard.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the kitchen and client bathroom and was not within the required range of 123.9 – 125.9 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers was observed and is fully charged.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 12/01/24.
(Continued on the LIC809-C)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL GLENDORA
FACILITY NUMBER: 198600156
VISIT DATE: 01/21/2025
NARRATIVE
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Staffing: There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location within a locked closet in the staff office area. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, Current First Aid/CPR/AED/CPI and sufficient on-going training. Administrator Agnes expires on 03/03/2025.
Client Rights-Information: Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained within the staff area in a locked closet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked kitchen cabinet and are in their original containers. LPA reviewed 4 client’s medications and all medications are given as prescribed by doctor.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency disaster plan need to be updated.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques, however, staff at facility do maintain valid CPI certificates.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit. Technical Advisory provided.

Exit interview was held and a copy of the report was given to Agnes Aguila.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2025 04:26 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/21/2025 at 04:07 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL GLENDORA
FACILITY NUMBER: 198600156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The water temperature in the bathrooms ranged from 123.9 to 125.9 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Administrator will adjust water temperature and keep a log for seven days and send to LPA as proof of correction.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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