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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600250
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:53:30 PM

Document Has Been Signed on 11/05/2021 02:53 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 MONTEREY PARKFACILITY NUMBER:
198600250
ADMINISTRATOR:MOHAMMED SHIRAZIFACILITY TYPE:
735
ADDRESS:435 DE LA FUENTE STTELEPHONE:
(626) 665-1080
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 4CENSUS: 4DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Mohammed Shirazi, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an annual inspection with the focus of the Infection Control domain. LPA arrived unannounced and explained the purpose of the visit to the staff who allowed entry. The facility Administrator, Mohammed Shirazi, arrived shortly thereafter.
The facility is licensed for four (4) Non-Ambulatory Developmentally Disabled adults from 18-59 years old.

LPA Chan toured the facility with Staff and observed/inspected the following:
* Temperature is taken prior to entry and an area is set up by the entrance to screen visitors for Covid-19 (Coronavirus) symptom screening.
* Proper signage are posted in the facility and in the bathrooms to promote hand washing.
* There are a total of 5 bedrooms; 4 for clients and 1 for Staff. Client bedrooms all have the required furniture and lighting. There are 2 bathrooms at the facility.
* There is a functional smoke detector in every room and one carbon monoxide detector in the house.
* The hot water temperature was measured within the range of 105-120 degree F.
* Disinfectants are stored and locked in the laundry room, located in the backyard. Knives are stored and locked in the kitchen cabinet.
* Sufficient food supply of 2-day perishable and a week of nonperishable were observed.
* All staff on duty wore a face mask.
* There are no bodies of water or pool at the facility. No items obstructing the walkways.
* Medications were reviewed for all 4 clients and are given as prescribed.

There are no deficiencies observed during the visit. An exit interview was conducted. A copy of this report along with the appeal rights were provided to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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