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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600521
Report Date: 04/13/2022
Date Signed: 04/13/2022 04:19:47 PM

Document Has Been Signed on 04/13/2022 04:19 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 ALHAMBRAFACILITY NUMBER:
198600521
ADMINISTRATOR:MASAYON, HIRAMOWEN (OWEN)FACILITY TYPE:
735
ADDRESS:1101 GERANIO DRTELEPHONE:
(626) 665-1080
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 4CENSUS: 4DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Ariel Dela Cruz, House leadTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an annual inspection with the focus on the Infection Control Domain. LPA Chan arrived unannounced and met with house lead, Ariel Dela Cruz, who allowed entry. Administrator, Owen Masayon, arrived shortly thereafter to assist with the visit. The facility is licensed for 4 Developmentally Disabled adults ages 18 through 59, of which two may be non-ambulatory. There are currently 4 Eastern Los Angeles Regional Center (ELARC) clients in placement.

The facility consists of 4 client bedrooms, 2 bathrooms, living room, dining room, kitchen, activity room, and a detached garage. The facility has an approved mitigation plan in which they are still following.
The inspection consisted of the following:
  • Screening and temperature logs were observed for both clients and staff.
  • COVID-19 signage were posted throughout the home.
  • There were sufficient supplies of 2-day perishable and a week of non-perishable observed.
  • Each client bedroom had the required furniture and is well maintained.
  • PPE supplies for at least 30-days are in storage at the home.
  • Sharps, knives, and cleaning solutions were locked in the cabinet below the kitchen sink.
  • Medications were locked and centrally stored in the kitchen area. LPA reviewed the medications for all 4 clients and they are being administered as prescribed by the physician.
  • The hot water temperature in the bathrooms were measured between the required range of 105 - 120 degrees Fahrenheit.
  • Fire extinguishers were observed to be fully charged and last inspected on 12/16/21.
  • All staff are wearing face coverings.
  • Staff clean every 2 hours - log is filled out and signed by performed staff


LPA did not observe any deficiencies today. An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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