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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600640
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:35:30 PM

Document Has Been Signed on 02/24/2022 02:35 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 ROSEMEADFACILITY NUMBER:
198600640
ADMINISTRATOR:MOHAMMED SHIRAZIFACILITY TYPE:
735
ADDRESS:1702 ROBIN LINDA LNTELEPHONE:
(626) 927-9177
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Mohammed "Raymond" ShiraziTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Mohammed "Raymond" Shirazi and explained the purpose of the visit. There are four (4) level 4N developmentally disabled resident; of which three (3) are 60 years and older. The facility is serviced by Eastern Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood that is licensed for 1 non-ambulatory residents and 3 ambulatory residents. It consists of 4 resident bedrooms, 1 staff room, 2 full bathrooms, living room/dining area, laundry/office area, kitchen, and detached garage. The last fire drill was conducted on 1/30/2022. Administrator certificate expires 11/16/2022.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. Staff were observed wearing surgical masks.
  • COVID-19 Infection Control screening and signs were observed in the entrance area, and bathrooms.
  • Facility has an approved COVID-19 Mitigation Plan.
  • Each resident room is designated as a COVID-19 solation room if needed.
  • Two (2) centrally stored resident medication record was reviewed.
  • Residents in care do not wear masks because it is not tolerated due to developmental disability.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • Personal Protective Equipment (PPEs) were observed.
  • The Emergency Disaster Plan was posted.
*** Age Exception for 3rd resident over the age of 60 was not processed/approved in October 2018 because the Regional Center support letter was not submitted. LPA spoke with Christopher Trevilla today.
Deficiency was cited.

Exit interview was conducted with Administrator Mohammed "Raymond" Shirazi. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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Document Has Been Signed on 02/24/2022 02:35 PM - It Cannot Be Edited


Created By: Noemi Galarza On 02/24/2022 at 02:21 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 ROSEMEAD
FACILITY NUMBER: 198600640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
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 above in that there are a total of 3 residents over the age of 59, and an Exception Waiver is not in place. In 2018, there were 3 residents over the age of 59, and an exception request was submitted, but the Regional Center support letter was never received; which poses/posed a potential health, safety or personal rights risk to persons in care. This requirement is not met as evidenced by:
POC Due Date: 03/24/2022
Plan of Correction
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Administrator shall submit an Exception request for residents over the age of 59 by POC due date. If an extension is required submit a written request by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


LIC809 (FAS) - (06/04)
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