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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600521
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:58:39 PM

Document Has Been Signed on 11/30/2023 04:58 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 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:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:02 AM
MET WITH:H. Owen MasayonTIME COMPLETED:
05:04 PM
NARRATIVE
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LPA made unannounced visit to follow up on incident that occurred on 11/23/2023 at approximately 12:40PM. LPA met with lead Ariel de la Cruz and Administrator H. Owen Masayon arrived a short time later and assisted with the visit. LPA explained the purpose of the visit.

LPA took tour of facility and did not observe any health or safety concerns at the time of visit. LPA measured hot water and check food supplies and it was in compliance within regulations,

On 11/23/2023 at around 12:40PM, DSP Cornelio Sanga was washing dishes and someone appeared outside the kitchen window by the sink and asked if this was people care, while that was occurring R1 opened the front and made it to the middle of the street. The other staff Illumidado Pajao was in the back doing laundry during this time and was unaware that R1 had left the home. Two community members attempted to assist R1 back in the home and R1 became agitated. The two community members assisted R1 from the street to the lawn across the street. Cornelio attempted to get R1 back in the home but R1 refused and Staff Cornelio asked two females from the community to watch R1 and they held R1 hands while staff Cornelio goes back in the home and get the other staff Illumidado to assist R1 back in the home. Then both staff went across the street and brought R1 back home. Police came to home and interviewed staff and left. R1 did not have any invisible injuries according to Administrator. Regional Center investigation is pending.

The fact that resident was able to leave the home and make it to the middle of the street posed/possess a health and safety hazard for clients in care.

Deficiency cited, see 809D for details.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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Document Has Been Signed on 11/30/2023 04:58 PM - It Cannot Be Edited


Created By: Alberto Lopez On 11/30/2023 at 04:33 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 ALHAMBRA
FACILITY NUMBER: 198600521

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision; (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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The Administrator will provide written plan of action, explaining how they are going to assure that while clients are present at the facility the staff will supervise the clients as required to avoid possible health and safety issues. Administrator will also provide in service to all staff and send proof to LPA by POC date.
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Based on interviews and record review the Licensee did not assure that the facility clients are supervised as required per Title 22. R1 left the facility by walking thorough the front door and made it to the middle of the street. This poses an immediate health and safety risk to clients 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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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