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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600250
Report Date: 01/05/2024
Date Signed: 01/05/2024 03:16:22 PM

Document Has Been Signed on 01/05/2024 03:16 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:JENNIFER PICHINTEFACILITY TYPE:
735
ADDRESS:435 DE LA FUENTE STTELEPHONE:
(626) 289-2320
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 4CENSUS: 4DATE:
01/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Mohammed Shaira, AdministratorTIME COMPLETED:
03:22 PM
NARRATIVE
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During the course of a complaint visit LPA measured hot water in 2 restrooms and it measured 125.9 and 129.0 degrees F which is not within range of 105-120 degrees F.

Staff adjusted the water temperature during the visit and it measured 120.2 in one restroom and 129.0 in the second restroom which is still out of range.

Kitchen water temperature was within range.


Also, there is a staff room adjacent to room #4 that is not on facility sketch.


Deficiencies cited on 809D.

Exit interview, report, citation and appeal rights provided to Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 01/05/2024 03:16 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/05/2024 at 02:32 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 MONTEREY PARK
FACILITY NUMBER: 198600250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2024
Section Cited
CCR
80086(a)

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80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. The requirement was not met as evidenced by:
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Facility will revise the facility sketch to match the actual physical plant. Facility will contact the fire inspector to ascertain if a new fire clearance is needed. All is due by 01/12/204
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LPA observed a staff room adjacent to room #4 that does not appear on the facility sketch.
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CCR

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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: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


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Document Has Been Signed on 01/05/2024 03:16 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/05/2024 at 02:40 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 MONTEREY PARK
FACILITY NUMBER: 198600250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2024
Section Cited
CCR
80088(e)(1)

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(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:
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Licensee will adjust water temperature to meet requirements. Licensee will maintain a water log for the next 7 calendar days and record water temperatures every 12 hours. Proof of water log must be submitted via email by 01/12/2024
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LPA measured the hot water in facility restrooms and it measured 125.9 and 129.0 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
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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: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


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