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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600250
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:59:37 PM

Document Has Been Signed on 09/24/2024 03:59 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 MONTEREY PARKFACILITY NUMBER:
198600250
ADMINISTRATOR/
DIRECTOR:		SHIRAZI, MOHAMMEDFACILITY TYPE:
735
ADDRESS:435 DE LA FUENTE STTELEPHONE:
(626) 289-2320
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 4CENSUS: 4DATE:
09/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:01 PM
MET WITH:LIna Cuento, DSP and Mohammed Shirazi, Administrator. TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit to follow up on Regional Center inspection report dated 04/23/2024. LPA met with DSP Lina Cuento and Administrator Mohammed Shirazi showed up short time later.
LPA reviewed and obtained staff and resident rosters, copy of activity calendar, cover sheet of 2021 first aid manual, Copy of Regional Center report with recommendations.

The following was inspected by LPA due to recommendations from Regional center.

1) Shower chair to be stored inside the facility.
LPA observed shower chair inside the facility.

2) The outside backyard needs cleaning and organizing.
LPA observed the back yard to be clean and organized.

3) First aid manual is 2014 edition.
LPA observed the updated 2021 first aid manual at facility which meets department requirements.

4) There are not many community and recreational activities on weekends occurring.i
The facility developed a picture booklet to gauge resident interest for activities and staff are able to communicate with residents and gauge their interest when going out shopping or other places.

LPA reviewed the title 22 deficiencies and observed corrections during visit.

No deficiencies cited during visit.

Exit interview conducted and copy of report and appeal rights provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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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