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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600627
Report Date: 10/21/2024
Date Signed: 10/21/2024 12:44:31 PM

Document Has Been Signed on 10/21/2024 12:44 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:DIMENSIONS DAY PROGRAMFACILITY NUMBER:
198600627
ADMINISTRATOR/
DIRECTOR:		GOODUS, DARRYLFACILITY TYPE:
775
ADDRESS:1757 NORTH LAKE AVENUETELEPHONE:
(626) 398-4435
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 75CENSUS: DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:54 AM
MET WITH:Montrey Vaughn, Program Coordinator TIME VISIT/
INSPECTION COMPLETED:
12:57 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Montrey Vaughn, Program Coordinator and explained the reason for the visit.

The facility is licensed as an adult day program to serve a total of 40 ambulatory and 35 non-ambulatory developmentally disabled clients between the ages of 18 to and 59. The facility is located in the back of a church and it consists of: lobby/history room, main hall (activity room), kitchen, 2 bathrooms containing various stalls and sinks, a sensory area, administrative/staff office, nurse office, copy room, participant and staff locker room and a changing room.

LPA toured the facility with Montrey Vaughn, Program Coordinator and observed the following:
Facility is in good repair indoor and outdoor. The activity room has different tables and chairs for participants to work in groups. Sufficient staff was observed. Kitchen is not used to prepared meals unless they are having an activity. Refrigerator used to store participants meals was observed clean. Changing room, and bathrooms were observed clean and in working order. Woman's restroom sink has accumulation of hand soap on a part below the sink. Water temperature was tested in each available sink and tested between 101.6 – 137.9 degrees F., which is not within the required 105-120 degrees F. Facility has smoke/carbon monoxide detectors in the main hall, nurse office and lobby area. Two smoke/carbon monoxide detectors did not operate when tested. One in the main hall and one outside the changing room. Cleaning supplies were locked in a closet near the changing room.

LPA reviewed 5 participant and 5 staff files.

Emergency disaster plan was reviewed, and last Emergency/Disaster Drill was conducted on 10/02/24. Fire extinguishers were lasted checked on 6/05/24 and 9/18/24. The emergency disaster plan need to be update.

Deficiencies were noted during this visit. Technical Advisory provided.

Exit interview was conducted with Montrey Vaughn, Program Coordinator and a copy of this report was provided along with appeal rights. .
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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Document Has Been Signed on 10/21/2024 12:44 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/21/2024 at 12:09 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: DIMENSIONS DAY PROGRAM
FACILITY NUMBER: 198600627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. the facility had two inoperable carbon monoxide/smoke detectors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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Licensee will repair or purchase new carbon monoxide/smoke detectors and send proof to LPA by POC date,
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA tested the water in the facility and it ranged from 101.6 in one changing room to 137.9 degrees F in the kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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Licensee will adjust water and keep a water log for 7 days and send to LPA as proof of correction.
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: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/21/2024 12:44 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/21/2024 at 12:09 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: DIMENSIONS DAY PROGRAM
FACILITY NUMBER: 198600627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. In the woman's restroom, there is an accumulation of stale soap on a part of the sink which should be cleaned which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee will clean the accumulation of hand soap and send LPA proof by POC date.
Type B
Section Cited
CCR
82088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. One window screen is missing in one changing room and the other requires a good cleaning which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee will purchase new screen and clean the other screen and send proof to LPA by POC date.
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: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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